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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 BOA 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 Countlty,Public Health Services. �/ Job Address 4 �' °at -1 Co �o VX' ( City %_03 f Lot Size/Acreage � /��rr- Owner's Name a / Address �a /�il '`®-u`0Ay Phone ? I"1 3 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT Ll DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION ❑ S`/STEM 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 CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �. ('i Public 11 Other ll Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U 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 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living'units: ---1--= Number.of bedrooms r, Character of is to a depth of 3 feet: f V flu^ Water table depth v SEPTIC TANK I W Type/Mfg C(2 AC_('c:,tt:. Capacity t- 00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal V1 Distance to nearest: Well Foundation Property Line LEA.CHING'LINEg �/o Total length/size v J�l No. & Len Length of lines FILTER BED Cl Distance to nearest: Well Foundation- _��., ....-_ Property Line SEEPAGE PITS 11 Depth r Size Number SUMPS LI Distance to nearest: Well f ! Foundation c�► Property Line yO 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, 1 shall 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 required inspections. Complete drawing on reverse side. Signed X, Title: + W N'G Date: F RDEPARTMENT USE ONLY l_,L Ems. ^� � f � /(` t Application Accepted by - L, `_ x, Date ` Area �rt or/lGrout Inspection by-5��. ~ -- Dat ' 2 r�e6 Final Inspection by—t'V �-_� Date �ltld oval 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 CK RECEIVED BY DATE PERMIT NO. INFO CASH :. }` j a EH t3-2�(REV.riHsi ) M i�l i.. �. �� r l� t -'.t: - /, !`�� `t i D �l2 EH 9<-2e