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f, f All - � �- APPLICATION FOR PERMIT SAN JO QUIN COUNTY PUBLIC HEALTH S VICES ENVIRONMENTAL HEALTH DIVISION 1602 E. HAZELTON AVE. , PHONE (209)46$-3420 P O. BO% 2009, STOCKTON, CA 95201 PEMIT MIREa I YEAR FROMDATE ISSUED (Complete in Triplicate) t Application is hereby made to Sao Joaquin County for a permit to construct and/or Install the work herein described. This application is made in cootpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address � �� City n Lot Size/Acreage ~ t7Src� Owner's Name Addre �D`�►.:.�.� . ��'a\ a Phone �► '+� Contractor crcaQ��.�.�Oe License No ��'�� Phone TYPE OF WELL/PUMP: RtW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Li PUMP INSTALLATION ❑ SYSTEM REPAIfi ❑ OTHER ❑ d, lvlonitoriIng Well •,11 Y� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ~IL LRU DISPOSAL FLD. — PROP. LINE 'bO a FOUNDATION `~ AGRICULTURE WELL — OTHER WELL 41tiJ PITS/SUMPS y f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a,� C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excava on Dia. of Well Casing 3i Domestic/Private I&G(ave! Pack ❑ Tracy Type of Casing V t-- Specifications I'1 Public Cl Other n Delta Depth of Grout Seal 'r � Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l 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 1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line • 1 LEACHING LINE ❑ No. & Length of lines Total length/sire FILTER BED O Distance to nearest: Wall Foundation Property Line SEEPAGE PITS if Depth Size Number j SUMPS Ll Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ i 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 I rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenif'rett 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 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 for all reauired ' spections. Complete drawing on reverse side, Signed _ Title ~ L` ate: \�� FOR DEPARTMENT US LY � Z ST Application Accepted by q q Date Area �1 Pit or Grout Inspection by Date T1_ 4 I �_– Final Inspection by Date r' 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 to kton, CA 95201FEE INFO A/MOOUNT DUE AMOUNT REMITTED CASH tEIV D BY OATS j+ PERMIIT7'NO. AI1 . £K t}ZI I�IiY.t/�Si�' l [Ji �"`-i �� 4 -.i f/✓`Ei� £M:1•le