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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 0 BOX 2009, STOCKTON, CA 95201 E%P RES 1 YEAR FROM ATE ISSUED (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 and the Rules and Regulations of San Joaquin County Public Health Services. �JobAddress 3 r- City Lor , Lot Size/Acreage Owner's Name ti►rne di` Address Phon ,iiems p kExPE ontractor E$R-T1� Ake t K1 Address `?0.1-1 '135 LQ&,.l X_ __ License No. S9©�� Phone i46-1570 OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE: FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public (-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done .L7 Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth ` Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION 1pmllteplic 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 Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: r Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation property Line DISPOSAL PONDS © ' 's 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." J �JThe applicant must call for all required inspections. Complete drawing on reverse side. gned X ?:;fu Title: ._CO IJP "T-olz_ Date: t4 J� F R DIEPARTMENT USE ONLY Application Accepted by Date1 Area Pit or Grout Inspection by Date Final Inspection by Dated- ll 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, Stockton, CA 95201 IN MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY a DATE PERMIT'NO. . EH17-211RtV.tK51 00 '72 ! CH 11.26 t -?-�