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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 EXPIRES I YEAR FROM PATE (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. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Av C C City» �T LY Lot Size/Acreage Qo,� O rrr C Owner's Name 5 T'' Address i• l C,3'2- CA ` 52 11 Phone ` - 7 Contractor t3" r Address �lrlr C'l'�1r r. (':c�lc _ L'+cense No. )r142 Y _Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ,,Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK N14 SEWER LINES DISPOSAL FLO. PROP.iLINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tr G,IrIndustrial ❑ Open Bottom C1Manteca Dia. of Well Excavation!Q-t,cIN Dia. of Wel! Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing tU Specifications f'1 Public M Other n Delta Depth of Grout Seal Type of Grout bcai t(Uwff r I I Irrigation -EDApprox. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 5 Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 bac a subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C omnia." l The applican must cap for requir pe tions Complete drawing o reverssee side. i SignedAMM Title: 7 i 1 mate:I P. (�� FOR DEPART ENT USE ONLY Application Accepted byNAY L/ Date 3 r Area �.-� r Pit or Grout Inspection byrDate � Final Inspection:by Date Additional Comments: ORP, O�, GC-�•r �C �+ � it7Z-1QRL6 01PAP ,1PGh31� P, tw.LM4 Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 200 tockton, CA 95201FEE ""{{ kNiF�O AMOUNT DUE AMOUNT REMITTED ASH EEV D aY DATE PERMIIT''NO. . EH 11,24 TREY.t i rl51 A y A EH 11-2e - x - - __ ..,a� .. . ,7 ra.�'�.r"l.i�'w�*- + trdri< Cn}.tc- . . .,fT}_. .�:xr� ��• K