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APPLICATION. FOR PERMIT l xnj, / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y 1601 E. HAZELTON AVE. , PHONE (209)468-3420 , P O BOX 2009, STOCKTON, CA 95201 PRMIT EXPIRES 1_ YEAR FROM DATES ISSUED (Complete in Triplicate) Application is hereby made'to Sam 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. Job Address �/` � / T-oE_ 7 r V City { , Lot Size/Acreage , Owner's Name ;ISL j 6y - C _-_-_ Addres�r- "// ' l�/!-/ �1� - _- _ _ _ Phone !�� Contractor I�/ � .. (/ ''"— Address �� 1� w ense NoeL/�Phone TYPE OF WELL/PUMP: NEW WELLAD WELL--REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION-❑ __sys6rEm REPAIR.0--. — OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK ��""�' SEWER LINES t DISPOSAL FLD. PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; F1 IndustrialOpen Bottom ❑ Manteca •' Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -LL Specifications i I'1 Public El Other n Delta Depth of Grout Seal _ _Ja Type of Grout � x I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - 1 # Repair Work Done U Type of Pump SU�h H.P. �,.. .,.,._ _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth + #{ i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION # I (No septic system permitted if-public sewer is available within 200 feet.l ti M 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 r , Distance to nearest: Well Foundation Property Line f LEACHING LINE ,._� Cl- No. & Length of lines Total length/size t FILTER-BED d Distance to nearest: Well Foundation Property Line E; F4. SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation '" Property 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 laws, and rules and regulations of the San Joaquin County -, 'i ' 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 subcontracting 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 compansa- °r tion laws of California." �,r The appli nt m t ca�or qui d r petitions. C m le drawing on reverse side. Signed X Title: Date: �/ 9� fQR-DEPARTMENT USE ONLY Application Accepted by Date S' `� l� 3 Area Pit orro Inspection by f Date� {Final Inspection by Datel��—Z4-:�� l ti .Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOVNT REMITTED CASH CK A RECEIVED BY DATE PERM17'N0: � a /DEHtIREV.t/NSI �� ! 7 4- I r _ II �