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c�'C 1 APPLICATION FOR PRRUIT ' - - r�s J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � !►� ��► 601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 S>� (Complete is 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 1862 and the Rules and Regulations of Sari Joaquin County Public Health Services. JOb Address Lot `Size/Acreage N Owner's Name�J �" Ib ��`^ Addresa7�� ^ac o.\ �D �i Phone cb,rct��.su4�c'� Z-n�.. 'Aye\� • 1 Contract., '+-«U`Q"^�: AAddressL TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES v�J - DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL!-_\5. �l _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of WellZasing n Domestic/Private .Gravel Pack ❑ Tracy Type of Casing QvL' Specifications 11 Public n Other n Delta Depth of Grout Seal v _T pa of Grout JI Irrioat�ion Approx. Depth 1 I Eastern ti Surface Seal Installed by R'e�a Wo+k Done ` U of Pump K.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material g Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_;,,^ Other Number Of living units: Number of bedroom$ Character of soil to a depth of 3 fat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property tine LEACHING LINE CI No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Properly 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 taws. 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 compensallon laws of California."Contractor's hiring or sub-conlracting signature mi i issued, I shall employ persons subject to workman's co nss- . certifies the following: "+unify that in the perlormance of the work for which this per t s ed, pl y pe !s mpg tion laws of California." The applicaet must tali for all requ, inspections. Complete drawing on reverse side. 1 Signed Titk: Data: FOR DEPARTM NT USE ONLY Application Accepted by Date 2' Ana Pit or Grout Inspection by Date Final Inspection by Date Y. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health _r Services, Ravironmental Heslth Permit/Services C r 1601 S. Hat:elton Ave.. P 0 Box Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Cts A C IVED BY DATE PERMIT-NO. INFFOy� /}��(J, �C/7ASH . EM t}7l INEV.11 A 5) W \ V J ��v "� •• �J+�� 1 I z J —4 - EM:�.