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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 HERMIT 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address //,C/! 1 l Z�Zz�Y Za--n-ey_�yQ�^ Cit Lot Slie/Acreag ��a L, Ow \ 4' ddress ��7n kf Phone 1 Contractor Address _ License No. Phone T11 YPE OF L/PUMP: NEW WELL ❑ WELL REPLACEMENT l-1 DESTRUCTION Out of Service Well PUMP INSTALLATION D SYSTEM � LREPAIR O OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK L SEWER LINES MLt e2_ DISPOSAL FLD.&2_�PROP. LINEW.Z FOUNDATION AGRICULTURE WELL OTHER WELL_Z _'EL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA' •CONSTRUCTION SPECIFICATIONS Ll Industrial 0 Open Bottom ❑ Manteca i , Dia. of Well Excavation_.�: Dia. of Well Casing ,.l Domestic/Private Ll Gravel Pack n Tracy Type of Casing 'Specifications I'1 Public 1:1 Other I 1 Delta Depth of'Groul Seal Type of Grout 11 Irr,Bation __.Approx. Depth ._ l I Eastern Surface Soul Installed byI Repair Work Done .1:1 Type of Pump H.P. State Work Done _ ~Well Destruction Well Diameter Sealing Material 3 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSrALLATION I I REPAIRIADDITION I I DESTRUCTION ISI^tNo septic system permitted if public sewer is S available within 200 feet.l 1i Installation will serve: Residence Commercial_ Other i Number of living units: Numtier'df bedrooms l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type'/Mfg Capacity No. Compartments PKG:TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Ll No. & Length of lines �� _ ' Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line l SEEPAGE PITS 11 Depth _ Size _ _ Number C SUMPS 1.1 Distance to nearest: Well Foundation ` Property Line i (� + DISPOSAL PONDS ❑ I {� 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, I shall not j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature t 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 appli nt must ` ired inspec o t raw n r�a se side. `Signedittf {e: ��h�-�/`z� Date: n. _ _ FOR DEPARTMENT USE ONLY Application Accepted " _ Date 12 Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments:^ Appliceaty-Ret WL1_l copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ,FEE ' INFO AMOUNT DUE ` AMOUNT REMITTED CASH r RECEIVED BY <-L DATE »PERMIT NO. • E>tt]NIREY.tinsr ?V C1 /� 7 S L CI �1,96 200-13-a,31 �. EM i16•1e