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'w 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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application'is made in compliance vith San Joaquin County Ordinance Po. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. bettA Li rd s" st q Ald Job Address ""`'t�� ZS�3hd DPD lAlal�.r t'�1dlY1YlG� city >tbck--�M Lot Size/Acreage I' Owner's Name GJv OT S l D Address-30s /v• �►d orad d , tS �� Phone q y`i- %5-38 Contractor nl& Address 41 674 Chn t Mbn1 'License No. S Phone 5 TYPE OF WELL/PUMP: NEW WELL5pL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring He11S 1p{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL DOf PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !! O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ErGravel Pack ❑ Tracy Type of Casing FgS0 PVC Specifications-FL4M I"1 Public n Other F►'Delta Depth of Grout Seal ?J Type of Grout CE✓IrIP�✓I�i r �1/1I,�II atto ry� �O Approx. Depth I I Eastern Surface Seal Installed by Repai�ork Dori✓ U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION t I DESTRUCTION l I INo 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. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby Certify that 1 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 laws of California." Contractor s hiring or sub contracting signature`s 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 call for all r irad inspgctions. Complete drawing on reverse side. SignedTitle: 10 Date: Oil 3 S rl�s `sLq �OR DEPARTMENT USE ONLY Application Accepted by Date l ( 2 Area Pit or Grout Inspection by Date .3- //—c,2—Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health n R� Services, Ravironmental Health Permit/Services �f 1601 L. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED B� DATE PERMIT N0.