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�} !I 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 IT l� RES 1 REAR FROM D i� (Complete in Triplic�te) ;1' Application is hereby made•to San Joaquin County for a permit to construct snd/or.ilinstall the work herein described. This application ion is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i pp I Joaquin County Public Health Services. # I u49 City EAT Size/Acreage Job Address I II. nk of StoVCktLDn Address Phone Owner's Name —Ba Contractor West Eiazmat Address 3233 Fitz erald License No. 554979_ • Phone 7E I" " TYPE OF WELL/PUMP: NEW WELL Ck WELL REPLACEMENT it DESTRUCTION ❑ out of Service Well Ll { F 0 OTHER ❑ Monitoring Well SYSTEM REPAIR PUMP INSTALLATION ❑ lar n/a r DISPOSAL FLD. PROP. LINE "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES )Q-- } FOUNDATION AGRICULTURE WELL fOTHERjWELL r PITS/SUMPS �> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w rr C1 Industrial ❑ Open Bottom ❑ Manteca Die. of Weil Excavation 0 TL Dia. of Well Casing C) Domestic/Private Cl Gravel Pack © Tracy Type of Casing sAed 40 PVC Specifications— Delta 1 Other t� Delta Depth of Grout Seal �r 1� Type of Grout ('I Public sand Pk „ i I litigation 25-'Approx. Depth l I Eastern Surface Seal Installed by_�Mr,i 1 1 AX! Repair Work Done U Type of Pump H.P. StateWork Done c Well Destruction ❑ Well Diameter Sealing Material 6 Depth:i_ Depth Filler Material 6 Depth A r TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADOITION l I DESTRUC. ION t I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity_" No. Compartments PKG. TREATMENT PLT.Cl [� � Method of Disposal Distance to nearest: Welt Foundation { ("Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation If Property Line Jl IM" SEEPAGE PITS [ I Depth Size 1( Number SUMPS Ll Distance to nearest: Well Foundation II �M Property line DISPOSAL PONDS ❑ i, I hereby certify that I have prepared this application and that the work will be done in accordance IIw ith San Joaquin county ordinances, slate laws, and t rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the patio rmanceliof 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 lawsipf California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the psrforrnencl e of the work for which this permit is issued, Ilishali employ persons„subject to workman's compensa- tion laws of Cali rnia." it The applicantsttefotr all fired inspections. Complete drawing on reverse side. f Signed fiG},t.tii.�. . Title: Prnzcrrf t _ Date: _iii 749i i EnA DEPARTMENT USE ONLY Application Accepted byF i� Date Area L Pit or Grout Inspection by Date Final Inspection by�� Date 12-s Z Additional Comments: 1" Applicant – Return all copies to: San Joaquin County Public Health I Services, Eavironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 A"t?,y FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE INfO �n1i r� .1 Q • EM 13.24 IREV.i W fro `��, OO �y 3Z-- ►y�1� 5 1 L- q i I�JL EM