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APPLICATION FOR PERMIT ` z - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 pEpj1JT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) n Joaquin County for a permit to construct and/or install the work herein described. This Application is hereby made,to Sa application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /1 ' Job Address �� y r�Lt e ` pi 5C�_ City `-"OGk�ON Lot Size/Acreage - j�� ( (ice_ Owner's Name (may y_lP^-' Address Phone I/ "7_�2�i /(:�, v✓ Jv2`off-�O� Phone �I'r� ` Contractor 57EG;,�2ur"1 Address License No. tof service Well TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ OuMonitoring well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.9_-1_S,, C (� 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.SPECIFICATIONS17— r r� ❑ Industrial - do pen Bottom ❑ Manteca - Dia. of Well Excavation /O Dia. of Well Casing r Domestic/Private "ravel Pack ❑ Tracy Type of Casing /O Specifications 1'I Public fl Other FI Delta Depth of Grout Seal 7p Type of Grout 11 Irrigation IA,Approx. Depth t I Eastern Surface Seal Installed by vR XH/' Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ elf Diameter /� �j`f Sealing Material & Depth G`S'EE�✓I - .1 g. Depth ' `�e' Filler Material i Depth s�cT2JAl65- LT 'C �G.eor,�r - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INC 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line i' 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 t. rules and regulations of the San Joaquin County j 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 9 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 1. certifies the following: "I cenify 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 applica m I for all require ins ptions. Complete drawing on reverse side. - 4 / Signed _ Title: Date: 11 , FOR DEPARTMENT USE ONLY - fi Application Accepted by jj/,�/° ! Date ,J �� Area r tf-i ,._-'- - Date6L2 2 Final Inspection b �" ""�� Date /Z? q/ Pit or Grout Inspection by Y '�'` it 11 Additional Comments: Applicant - Return all copies to: San Joaquln County Public Health 1 Services, Eavirontriental. Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 , FEE AMOUNT DOEAMOUNT REMITTED CK CE ED aV DATE PERMIT NO. INFO CASH (; z„ is-z.IREV.r/.! I1J .L3Ci �- ��. i7 I . 5' Jll f J