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APPLICATION FOR PERMIT - r EIVED 9 E U SAN JOAQU IN COUNTY PUBLIC HEALTH SERVICE f ENVIRONMENTAL HEALTH DIVISION APR � ��RZ 1601 E. HAZELTON AVE. , PHONE (209)468-5420 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL. HEALTH EXPIRES 1 YEAR FROM DATE ED PERMIT/SERVICES (Complete in Triplicat4) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �Ot �O W LAMIP A Cit In Lot Size/Acreage C ! i Owner's Name �� Z a rvsb cLs— Address C , 68-MeAdC Ld, Phon04az 3 t7D i We.6�-w,A6 EJr,#fD3 4 6 (306) Contractor ddress '� (License No._� Phone Z TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION p Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ k OTHER ❑ Monitoring Well ❑ boo DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public n Other Fl Delta Depth of Grout Seal 5t&,( ACI? -M-1Type of Grout to 11�IS5r��rigla on . rr,, 4TLApprox. Depth KEastern Surface Seal Installed by: ,4 fep3i Work�Ddne ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter r r Sealing Material & Depth Depth Filler Material & Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is ; available within 200 feet.) i. Installation will serve: Residence_ Commercial— Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation r Property Line LEACHING LINE 0 No. & Length of lines Toti al length/site FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS El 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 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 taws of California."Contractor's hiring or sub-contracting 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 alifornia." The appli ant u call f requir inspections. Complete drawing on reverse side. f - Signed Title: +,1JC?�af}'� �"df�0 �1'I�I Sr` Date: 3 12-117,1 -3 FOR DEPARTMENT USE ONLY Application Accepted by,��/"_ Date " Area 9 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health no Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RE EIVED BY DATE PERMIT NO. tNFp CASH . EH 13.241ttEV.r/rs1 EH 14.20