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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 PBUIT EXPIRES 1_YEAR FROM DATE IS5U (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 1862 andtheRules and Regulations of San Joaquin County Public Health Services ( f / f ' %?� Job Address Lr �� City Lot Size/Acreage / X, 5 ' r �1 Owner's Name . Address �� PhoneT3 Y- 7 Address FLd�I�Q�(�lo ��d `y so Z�C� d 5.��$� Contract � r License No. Phone3('A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION '. AGRICULTURE WELL -OTHER WELL PITS/SUMPS T ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private LI Gravel Pack ❑ Tracy Type of Casing--- Specifications 1'I Public Cl Other 1 11 Delta Depth of Grout Seal Type of Grout - 1 I I Irrigation Approx. Depth t I Eastern Surface Soul Installed by. Repair Work Done 0 Type of Pump H.P. State Work Done J Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depc Depth TYPE OF SEPTIC WORK: NEW INSTALLATION>< REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is k / available,within 200 feet.) Z } Installation wilf'senre: Residence Commercial Other 'may Number of living units: 4— Number of dr m � i Character of soil to a depth of 3 feet: ` Water table depth 5 SEPTIC TANK Type/Mfg _QZR4 capacity� dFbNo. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation L5 Property Line _ 'T LEACHING LINE i!. No. 8 Length of linesi .y ,Total length/size_= II FILTER BED C7 Distance to nearest: Well_ - Foundation " Property Line ' _ s SEEPAGE PITS ~ Depth_ .`Q Size --.a -. .- 5'o Number SUMPS Distance to nearest: Well Foundation f o Property Line �S DISPOSAL PONDS ❑ I I hereby certify that I have prepared this rapplication 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,;i`Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this psr6t is issued, I shall employ persons subject to workman's compensa- tion laws of California." r ` The applicant t call for a re uir inspections. Complete drawing on re arse side,E.�,i, Signed X Title: =___-__ Date: 42 9 FOR �D1EP�ART3MENT USE OfVLY1. -5-- Application Accepted by Date Area / Pit or Grout Inspection by DateFinal Inspection by Date Additional Comments: r T Applicant - Return all copies-to:_s Sad'Joaquin County Public Health Services, Environmental Health Permit/.services ! '1601%E. Hazelton Ave., P`0:Box 2009, Stockton, CA 95201 FEE INFO AMOUNT„DUE . _._AMGUNT REMITTED CASH RECEIVED BY PATE AERM117NO a EH 13-24 VIEV.t/ns1 ENA-211 `' r