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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 is hereby trade 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �/ 8 Job Address u� Lot S�ize/Acres e 0_144 VSrT Address �TJ� �L�U r jL• Owner's Name C�Y j/�ui l/� el one r¢ Con lraCtOr/�' Address License��i� �y�� License No.��1lo Pho e TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT C DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK y41 SEWER LINES A-14 DISPOSAL FLO. A'14 PROP. LINE �20 r FOUNDATION N '� AGRICULTURE WELL OTHER WELL PITS/SUMPS � ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ir7l+Iel�Jljc,y,Zti?rgr5�❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing Z rrrSO�'v rO lb:�oc W Cl Domestic/Private ❑�Gravel Pack L3 Tracy Type of Casing��/'FOlJ/4`l0 I'-- Spastic Ions 1 Public LfOther (-1 Delta Depth of Grout Seal 2 T//, Type of Grout A, I Irnpation Approx. Depth I I Eastern O Surface Seal Installed by L Repair Work Done a Type of Pump CS�irK ' p State Work Done _ Z" O% Well Destruction 7J/Nell Diameter Sealing Material & Depth�7� , ,irie �p/-4/-/,i1/XtiA4''fA 3-S Depth �'S40 FtY Filler Material & Depth/ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) ^ Installation will serve: Residence_ Commercial _ Other r- Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth C_' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 7; PKG. TREATMENT PLT. ❑ Method of Disposal CC Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & 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 Cl 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 laws of California." Contractors 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 must call fo II i inspections. Complete drawing on reverse side j // � ��;da,. Z, Date: Signed Title: FOR DEPARTMENT USE ONLY ,•J' Application Accepted by C Date try�7 L� Area W Pit or Grout Inspection by Date -71. J1 90 Final Inspection by ij/L�/1' Date ! y F r N WJ> t�s�eck �,� E KW NAM jka yt�hW I nsnP�l�c� b�- M Additional Comments: '� " ""`^' Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009 tockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH R EIVED BY DATE PERMIT NO. INFO • EM 13-3/(REV.I/-S)W �/� EN