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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 costpliance with San Joaquin County Ordinance No. 11, and 1112 and the Rules and Regulations of San Joaquin County Public Health Ser ices. Job Addresses City&nsS2yAPt Size/Acreage if�A Address ?/ 3 ._/l c?PGL Phone Owner's Name R e,�a6 —6C — Contlactor l�4. L r J U( Address��Ltry7�A- License Ncy1602—Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ 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 ED Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' I'I Public C7 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by W 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 1 I" REPAIR/ADDITION DESTRUCTION-1-1-(No septic system permitted if public sewer is jell-/Commercial available within 200 feet.) ' Installation will serve: Residence _ Other - Number of living units: -I— Number of bedrooms `t Character of soil to a depth of 3 feet: J LA-41M Water table depth ' SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest;. / Well -- Foundation- Property Line LEACHING LINE No. & Length of lines F — Total length/size 1 FILTER BED Cl Distance to nearest:t Well Foundation, 4A """/ Property Line r^ ' SEEPAGE PITS 11 Depth Size i Number SUMPS LI Distance to nearest: r 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, (.shall not employ any person in such manner as to become"Elect to workman's compensation laws of California." Contractors 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 a requir inspections. Complete drawing on reverse side. qJ Signed -----uG 'i Title, p Date: y �— �J OR DEP TMENT U ONLY ! Application Accepted by Date Pit or Grout Inspection by Date Final Inspection ' Additional Com"Me: Applicant Return all COPlee to: San Joaquin County Public Health ' Services, Environmental Health Permit/Services ti 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SASH I RECEIVED SV DATE PERMIT NO. EM 13-24(REV I/M e) INFO ac.2cGv, �,11R • EH 1616 \ .