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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 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. r Job Address ZZ A/�V ',�!� City X � Lot Size/Acreage "� ( Z Owner's Name V/1 r lV 7AZ!'K l //'Address `� �� A/ �fL� �� Phone Contractor )- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ... PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public I.l Other 11 Delta Depth of Grout Seal Type of Grout w I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is 31 available within 200 feet.) S 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 SEPTIC TANK Type/Mfg L Capacity J�� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L'r No. & Length of lines Tptal length/size r FILTER BED ❑ Distance to nearest: Well 36 0 Foundation 50 Property Line SEEPAGE PITS 11 Depth Size Well-37f C1 Number d SUMPS LI Distance to nearest: WeII.Z.l C' Foundation -126 Property Line DISPOSAL PONDS ❑ 1 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: "1 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 ADust callfo all uire in ctions. Complete drawing on reverse side. Signed X �z 1,G-� Title: � .��' Date: Z r / FOR DEPARTMENT USE ONLY Application Accepted by ✓ /t�lf t DateF d A a or Grout Inspection by 94,11, Date Final Inspection by Date�V 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASN /� EH 13-24 IREV.I/n 51 , !•",J `,� "1 O 9.--769_ EH'4.2e " �!