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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH TERVICES 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 County Public Health Services. Job Address � � �L ZZt City Lot Sizecreage O*per's Name l7r71/tn nla vrx Address Phone br7Q Co4ltr�c26r 1__.('i�ZOS S �Sfm S-- Address License No. 6 3e2:2 Phone 7ti5J-2?1 TYPE OF WELL/PUMP: NEW WELL 'I?' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE A0 FOUNDATION AGRICULTURE WELL -- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'y C] Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Aileet Specifications FI Public Ll Other F1 Delta Depth of Grout Seal 4"&4(36� __ Type of Grout. tel" 6-1 Irrigation __ Approx, Depth I I Eastern Surface Seal Installed by 4i_ 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 I I REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number o tvt Number of bedrooms Character of sob to a depth o er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �p PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE L1 No. & Length of s Total length/size FILTER BED 11 Distanc nearest: Well Foundation Property Line SEEPAGE PITSI Depth Size _ Number SUMPS L_I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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 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 applicant must call for all squired nspections. Complete drawing on reverse s e. Signed X Title: - Date: TAV(-1 61 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byn Date Final Inspection by Date _ Additional Comments: Applicant'= Return all copies to. San Joaquin County Public Health v Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASCK H RECEIVED BY DATE PERMIT NO. EHt,. IREV.riNst �j CIU •�� CSU ?J 3