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�r 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 EXPIRES 1 YEAR FRPM DAIR ISSUED (Complete in Triplicate) Application is hereby made.to Ss.n 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /72-7 1'6ar )e_d City 6a/4 Lot Size/Acreage 700-4-1 Owner's Name �ak !G ��S'1 �2Nu.tis Address 1Qa � /add Phone S Contractor rr a 4to+� S�d�jY Address ( ��rw�ohdGf License No. 7 � 7- -1773 Phone 7a7 TYPE OF WELL/PUMP: NEW WELL C_],/ WELL REPLACEMENT ❑ DESTRUCTION 0 out of Service Well 0 PUMP INSTALLATION L7 SYSTEM REPAIR © OTHER © Monitoring Well C� 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 El Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation _ f6 Dia. of Well Casing N Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_ s1e,*aI Specifications I'1 Public RAI Other n Delta Depth of Grout Sea! `�� Type of Grout r It 4 lfrigation -79 Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION { I DESTRUCTION l 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: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby cenify 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 applicant t call for all required inspections. Complete drawing on reverse side, Signs- Title: 4. Date: 14 R DEPARTMENT USE ONLY C? q Application Accepted by CA QC,t,, Date Ll T Area Pit or Grout Inspection by Date Final Inspection by_l Date r / 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 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PPEIRMIT'NO. + EH t3-24 1flEY.I/%$) N ' EH 3-28