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h .VASB41CPLICATION FOR PE �A I�COUNTY P IC HE At F V.•iRONMENTAL ALTH I S�yjpAQo NHAZELTON AVE. , PHONE MQ 68-�' P 0 BOX 2009, STOCKTON, QPA C#)l S EXPIRES 1 YEAR FROM 1111 ED "" 11 (Complete in Tripli _ _ ut/ Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein escr his ` application is made in compliance with San Joaquin C unty Ordinance No. 549 a d 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��=�� }- r Job Address — � `7 � ` � � City t Lot Size/Acreage Owner's Name6l ' l � �Address Phone Contract • U ` Addre Licens r r Phone` rC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L) Out of Service Well Ll PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications, I'1 Public 1.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by JI Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth m Depth Filler Material & Depth l J TYPIi OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No 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: . %� L�� Water table depth SEPTIC TANK'- /SfD Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS �fyr Depth :e�� Size - /� _ Number SUMPS ✓LI Distance to nearest: Well Foundation 0 0 Property Line DISPOSAL PONDS ❑ 1 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." 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 applica=callquired ' spa tions omplete awing on reside. Signed X �� tle: Date: T��l FOR DEPARTMENT USE ONLY f A plic tion Accepted by Date Area Pit or Grout Inspection by Date y final Inspection by (ice(. C� I Date �FldA-� %f« •ler ti 5 c,A -�'r (�0 p4 i 7 Additional Comments: L `� v 6 Applicant -, Return all cop es to: San Joaquin County Public Health Sal Za_40 !J ✓.r '/ Services, Environmental Health Permit/Services ��g e, Az,-.) . f�45tiudA,— // 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201(c6FEE d ( l- INFO AMOUNT DUE AMQUNT REMITTED CAS CK RECEIVED BY DATE PERMIT NO. 4? / "5 1 .r 1, 11 13-241REV.r/nsl ( I � � • D .�� a/ 1 f-i �! �7/ l � // A / � �• 1 26