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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in .Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 77 7 / JJ Job Address `-/ 6r 54 �`•f City Lot Size/Acreage Owner's Name "�� vi2'i "'� Address >FQ0 fJ6Cz Phone eoe3 _64f 5' Contractor—a-Frr dtw� ysiL xMS °Address w'7o i.f.(G'�^Ao:, JEl�rv:S License No. y%3E�- 7 Phone S.3B-/773 TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION Lha SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation !6, Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications I'I Public R.'1 Other Il Delta Depth of Grout Seal Sa Type of Grout --e _ 10 Inigadon _7 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is Y available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Companments /1 PKG. TREATMENT PLT. Ll Method of Disposal / Distance to nearest: Well Foundation Property Line LEACHING LINE L7 No. i Length of linea Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant 11t call for all required inspections. Complete drawing on reverse side. Signed X _ �� t �a: Title: _ 4 Date: FQR DEPARTMENT USE ONLY t L n A Application Accepted by r \y\rQ Date -T _1 q l+f Area Pit or Grout Inspection by Date Final Inspection by ! -62 Date - C� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE jAMOUNT DUA AMOUrjT REMITTEDCK RECEIVED BY DATE PERMR-NO. INFG] EH 1 a! C.irn Si N .CTG ` L 1 { -- gay �. _ _ ` 1 (REV � i- I i 1 -r� tai