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APPLICATION FOR PERMIT ti SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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 Couaty Public Health Services. Job Address � /{(W � / City /n Lot size/Acreage Ownei s Name ya't I '7t�L�r.C� AddressA 1^o6 /✓i IJ��A= Phone 3G _ � Contractor "dress —f0- 6 PX 16 7 L�--.—License No.31p ,�' / Phone 6p S of TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications VI Public I_1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigatton —Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material 6 Depth )6 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION 11 (No septic system permitted it public sewer is p available within 200 feet.l Installation will serve: Residence X. Commercial_ Other Mo�, how if `0 Number of living units: __/_ Number ofb f oms 120 U Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK IR Type/Mfg . Capacity B/y 0 No. Compartments 2 PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well S� Foundation Property Line LEACHING LINE if No. 6 Length of lines Total length/size— 2 O FILTER BED ❑ Distance to nearest: Well Foundation J r Property Lines SEEPAGE PITS Depth Sire �� Number SUMPS LI Distance to near fesQst: Wall— Foundation/Q r Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 certifies 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 applican t call for 1 qu' d inspections. Complete drawing on reverse s l Signed _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 2 /�^/ f� Area r for Grout Inspection by ate r ^) Final Inspection by ZZ L Additional Comments: — Applicant — Return all copies to: San Joaquin County Public Health �inrl Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO I CASH EM 13'24 IREV.1 r x 51 EH;626 V•O U `�/ I O t]�1 D:17