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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1-NVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ! P O BOX 2009, STOCKTON, CA 95201 ER!(ZT 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. Th; application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sar Joaquin County Public Health Servicee. Job Address __ �_ se6Wmi44607 OW City " 'e Lot Size/Acreage S�C i Owner's Name ri & _ I Address Phone Contractor 46j-'�� 5 Address 6 License N 7730 S Phone 37� TYPE OF WELL/PUMP: _ NEW WELL 1W WELL REPLACEMENT it DESTRUCTION Cl Out of Serylce well C PUMP INSTALLATION SYSTEM REPAIR D OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES C. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELD ,l-OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 i Industrial ❑ Open Bottom 0 Manteca Dia of Well Excavvaaa ion•-�� Dia. of Well Casing j,eomestic/Private :Gravel Pack ❑ Tracy Type of Casing../ `fes. Specifications I'I Public (la Other { n Delta Depth of Grout Seal lr7[��- +_t#.�T,ype of Grout C� qtr I I IwUalion Approx. Depth I I Eastern Surface Seul Installed by C.,. i- 7 ! Repair Work Done U JType of Pump �c^� H.P. Z State Work Done S_Z�4e':�4 Well Destruction ❑ -Well Diameter _ Sealing Material Z Depth Depth — Filler Material i Depth C.' TYPE OF SEPTIC WORKS NEW INSTALLATION 1 1 REPAIRIADDITION I I DESTRUCTtON'I'.I.(No septic system peiinitted if public sewer is I { available within 200 feet.l Installation will serve: Flesidence + Commercial : Other Number of living units: Number of bedrooms f Character of soil to a depth of 3 feet: I _ --Water table depth_ SEPTIC TANK O Type/Mfg Capacity _ No. Compartments PKG TREATMENT PLT. ❑ ` Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines _ Total length/size FILTER BED Cl Distance to nearest: Well _ Foundation ___. Property Line SEEPAGE PITS 1"I Depth _ I Size _ Number SUMPS Ct 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 taws, a 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 $hall r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signan 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 compen lion laws of California." The applicant Gmust 11 f r all reOui ad inspections. Complete drawing on reverse side. Signed X_`/� f/ _._�. ----- Title: �'- - ----- ___ Date: ?'��— ��------ 1 FI DEPARTMENT USE ONLY Application Accepted by Date — —�U Area _ Pit or ro Inspection by~ �4 Date' Final Inspection by 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 NFO FEEAMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE eEAM1T NO. _ ._ n3