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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT MIRES 1 _YEAR FROM DATE ISS , (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. / rt 1' tax City �l Lot Size/Acreage Job Address �C.- Owner's Name � � "S Address Phone i I Contractor - - •� Address -J-22y License No. `� '� Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE y FOUNDATION -AGRICULTURE_W.ELL OTHER WELL -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications + CI Public CI Other n Delta Depth of Grout Seal Type of Grout l i I Irrigation App,rp'-Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth fj a •s _ I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITIO DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) j (/ Installation will serve: Residence-L Commercial Other Number of bedrooms Number of living � N $ units: Character of soil to a depth of 3 feet: 1-1 Water table depth _ SEPTIC TANK D Type/Mfg - f Capacityw�. No. Compartments w --PKG: TREATMENT PLT. ❑ •� Method of Disposal ' Dista ,nce to nearest: �" Well� Foundation Property Lime K LEACHING LINE ❑ No.,B Length of lines T_ Z�- - . . ___ Total length/size FILTER BED ❑ Distance to nearest: Well-Z� Foundation 00 r Property Line -` SEEPAGE PITS � 1 ) Depth Size Nu _jr SUMPS LI Distance to nearest: Well . FoundationProperty tineIV 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 Home owner or licensed agent's,signature certifies the following: "I certify that in the rforniance 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 compen-sa��u.n laws-of-Cslifornia.t 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 applicant_ t call for a spections. Completedrawing on reverse sided F� F -Signed Title: /�/�-.i'L'.�a_ - _ Date: r� /FOR DEPARTMENT USE ONLY Application Accepted by Date �,7 - Area - -- _ r P or Grout Inspection by G Date�?/3 ,? Final Inspection by Oatey� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health r Services, Enviroinmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 sFEE OUNT DUES MOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO T A r EM 13.24IRE V.��n51 AW C:� -7,d �� EH$42a