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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 kZMIT EXPIRES 1 YEAR FROM DATE- ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct'and/6r install the work herein described. This J application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San t Joaquin County Public t✓Health Services. Job Addressq/0 I K_A I° 2 W 1n_k1A -------- City Lot Size/Acreage Ze0_ Owner's Name Lit L _ .0 Address _7 r n,&D!,J 2 6_41 t'Q)LF f `t------- Phone 7y ,p r C.ontractor. ��L Address �� L�QVc-� �a License Nor$ ' Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION SYSTEM+! REPAIR ❑ OTHER El Monitoring Well ❑ a DISTANCE TO NEAREST: SEPTIC TANK I Of7_ '_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ?,- C) Industrial r]"Open Bottom;. 0 Manteca Dia. of Weli Excavation Dia. of Well Casing X.l"Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i•1 Public 1-1 Other ❑ Delta Depth of Grout Seal gype..of fcu I I trriUation a�.,Approx. Depth I I E stern Surface Seal Installed by �,y J t �I r 1� [F Repair Work Done 0 Type of Pump .h H.P.-3 -- _ State Work Done _ Depth & D i t M Sealing Material ep Well Destruction ❑ Well Diameter Sea Depth Filler Material & Depth X TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.► Installation will serve: Residence_ Commercial,.,W. Other Number of llving units: Numljer of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal <o � Distance to nearest: Well Foundation Property Line •j LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: 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 n 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 m st call for all require spsctions. Complete drawing on reverse side. Signed ZILTitle: S �>� Y_ Date: EPARTMENT USE ONLY Applies ccepted by2� ZRD Date S>j rl '� Area ` Pit or Grou Inspection by 4 .`~ Date Final Inspection by Date Addit al Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services '1601 E. Hazelton-Ave.,'P 0 Boz 2009,'Abckton,CA' 95201FEE - - INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + FH 13-24 rfltiV.t i n s) EH 41•Za •�