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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOR 2009, STOCKT N, CA 95201 MIRES 1 YEAR FROM DATE ISSUED C(OPY (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 501 Lot Size/Acreage 7'lli. o T%/_Y�(y;/5 GC1--- ] c vvv 3 Phone Owner's Name Address �� '�C.� Contractor V� fes' d)1 Address t '� �/� 1�'� Cr�� License No. 3'7(F'3Yf Phone 96�- �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well L1 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 V'001 WA-OTHER 14 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK IV SEWER LINES 2 DISPOSAL FLO. /V4' POOP. LINE 65 FOUNDATION AGRICULTURE WELL 14 OTHER WELL 200" PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ., _ G f7) industrial ❑ Open Bottom Cl Manteca Dia. of Well E)cavation_1 U17__ Dia. of Well Casing CI Domestic/Private `,Gravel Pack Ul Tracy Type of Casinf 5eif 8 rG Specifications I'1 Public 1-1 Other 171 Delta Depth of Grou Seal J9 _ Type of Grout W=41-lutA E I I Ifrigiation 6�Approx. Depth 11 Eastern Surface Seal Installed by �e l F1or1 f Repair Work Done U Type of Pump IrY� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Eepth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 ❑ Type/Mfg Capaci y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Properly Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 Workmen's compensation laws 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 of California." The applicant r ust call for all to uir d inspections. Complete drawing on reverse side. �7�lJLJ. j � r Signed X Title: Date: �+ t rLLLti/itG �i7/(i FOR DEPARTMENT USE ONLY Application Accepted by Date � 2oAF.. 3, _ Pit or Grout Inspection by Date Final Inspection I Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Pe t/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY / DATE PERMITNO. r CH 1124MEV.1/h51 EH 14.26sm / 1