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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 [IT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for n permit to construct and/or install the work herein described. s 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. T19Pe 7 Z City Lot Size creage Job Address < C'ah� -6 VC-11. Address Phone 0�,4ner's Name 1 7y —2?1 COAL act —-�H!z License too. 6 3C��/ Phone Z (�' 7�S S-d --Addr.ess� DESTRUCTION Cl Out of Service well 0 NEW WELL WELL REPLACEMENT ❑ i TYPEIOF WELL/PUMP: t Monitoring well L3 PUMP INSTALLATION O + SYSTEM REPAIR ❑ 4 OTHER O ! ;= DISPOSAL FLD. �- PROP. LINE _ DISTANCEITO•NEAREST: SEPTIC TANK s SEWER LINES t�J FOUNDATION AGRICULTORE WELL OTHER WELL PITS/SUMPS 1 — I t INTENDED USE TYPE OF WELL PROBLEMrAREA CONSTRUCTION SPECIFICATIONS Q1lntlustriel Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing Type of Casing see- Specifications z� C. 1mestic/Private 0 Gravel Pack 0 Tracy qS..�t Ia Other -.f� Delta 'Depth of Grout Seal Sb Typo of Grout., t f'1 Public l �A YlrriQation Approx; Depth 1 I Eastern ;Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done -- Sealing Material & Depth I Well Destruction O Well Diameter Filler Materiel 5 Depth i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION it I efvailabllIc system permitted if public sewer is t Installation will serve: Residence_ Commercial` Other t Number o rvi Number of bedrooms I er table depth Character of soil to a depth o - SEPTIC TANK O Type/Mfg Capacity No. Compartments i Method of Disposal PKG. TREATMENT PLT. ❑ j ! Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length o s t I Total length/size iClDistant nearest: Well f Foundation Property Line FILTER BED I SEEPAGE PITS I Depth Size Number ,- t I SUMPS LI :Distance to nearest: Well I Foundation Property Line t DISPOSAL PONDS n 1+ ork will be done in accordance with San Joaquin county ordinances, I hereby certify that I have prepared this application and that the wstate laws;and rules and regulations of the San Joaquin County Horne owner or Licensed agent's signature certifies the following: "I ceriify that in the performance of the work for which this permit is issued, I shell 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 comp�sa tion laws of California." f 1J The applicant must call for all squired 'nspections. Complete drawing on reverse.s' e. ` i }) / t �z-�2-go Signed X Title: _ ;=w� r mfr Date: Si I g 1 i FOR DEPARTMENT USE ONLY f / } 3 a Date Area ! Application Accepted by I ; 5 Date Pit or Grout Inspection by • - Date Final inspection by '- 4 Additional Comments: AppTicent=Ttettirn a�T1 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services + 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 1.X95201 FEE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. AMOUNT DUE CASH INFO 00 g9 . C-30 3 3 3 rn� �a- C c;1—�ca '3 aS y . EH U-24(REV.11 m 5i EH 14•2e .. ..--. _ ..... --_--��.•-- -_