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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 PEk3![Ix EXPIRES I YEAR FRQM 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 cotapllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address �u L/�U � 1�/S City ` U Lot Size/Acreage _ �Q r _owner;_Name_ /C . S �iQ�(:K Address __� _ ^ Phone { �" r Contractor ��5 7�/ Phone � Address�'dci�' � License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D out of,Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN1E (} !1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Cl Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation _ Dia. of Welt Casing I C1 Domestic/Private Cl Gravel Pack D Tracy Type of Casing Specifications I'l Public CI Other n Delta Depth of Grout Seal Type of Groul1 i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by ;- Repair Work Done U Type of Pump H.P. State Work Done I Sealing Material Depth Well Destruction ❑ Well Diameter i 1 Depth Filler Material i Depth s TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION ( I INo septic system permitted if public sewer is available ,within 2200 feet.) 0 Installation will serve: Residence ---- Commercial !� �� a' z Number of living units: Number o bedroo s `'�� s {r } .93/91 Water table de Q Character of loll to a depth of 3 feet: � depth I SEPTIC TANK W Type/Mfg (.aGl.� - 2 V'e Capacity GaOD__ No. Compartments PKG. TREATMENT PLT.D V f Method of Disposal Distance to nearest:, Well 20 Foundation /1 / Property Line 0 l LEACHING LINE 2r� No. b Length of lines ��` j Total.length/size f ) FILTER BED D Distance to nearest:T=We"7= 0 r Foundation I t Property Line/ { i SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ ` r r I hereby certify that I have prepared this application and that-tree-work-will be done in accordance with San Joaquin county ordinancesxstate laws, and rules and regulations of the San Joaquin County/ `ia 1 r . ,'— 1 d 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 shall not employ any person in such manner as to become subject to workman's compensation laws of'Caidomia."Contractor's hiring or sub-lcontracdng signature certifies the following: '"I certify that in.,the performance of the work for whi�h'ihis permit is issued,l hh ll employ persons subject to workman's compansa- II tion laws of California." `;a W_ 1 I The applic 51 ca I for all re irad nspactiontt. Complete drawing on reverse aide. I t Signed X, �6 j Title: V Wye Date: [O 6 70 .. 1FOR DEPARTMENT USE ONLY { Application Accepted by`;��4 y� _ ) Data z {S�- Area / ? Pit or Grout Inspection by Data r``"12 Tinal ction•1; Dat k i Additional Comments: 2 r Applicant - Return all copies to: San Joaquin County_Public,Health.�N Services, Environmental Hee -iermit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 z FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO . EH 13.24(REV.1"5) (�_ �� /� � 3 r v l ! 9 p S 8:::k- EH EH 3426 O