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F APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH'SEAVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE.,, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM-DATE 1,5SUED (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. Job Address _ v �'N € - City7;0C Lot Size/Acreage i ,. Owner's Name �r �� 1�lGs f�� > Address Phone Contractor i JGC Address C l � IWI(JoA License No.. -4:i __f hone y TYPE OF WELL/PUMP: ;N. . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER C3Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES; _DISPOSAL FLO. PROP. LINE_ _ FOUNDATION AGRICULTURE WELL OTHER WELL �PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; Cl Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private 0'Gravel Pack ❑ Tracy' Type of Casing Specifications i'1 Public Il Other f 1 Delta £ Depth of Grout Seal Type of Grout I Irrigation Approx. Depth I I Eastern Surface Seat Installed by i Repair Work Done ❑ Type'of Pump H,P. State Work Done—, Well Destruction ❑ Well Diameter Sealing Materiel & Depth + W P i Depth t•� ,Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION`( I DESTRUCTION I I lN6 septic system permitted if public sewer is aveiiabie within 200 feet.I Installatlbn will serve: Residence-L Commercialthen C k Number of living units: _� T Number of bedrooms; Character of soil to a depth of 3 feet: A A M er, Water table depth, r r SEPTI TANK. ❑ Type/Mfg `'Capacity No. Compartments PKG. TREATMENT PLT. ❑ t ! Method of Disposal Distance to nearest: ',(Well 1"141— Foundation vt3 Property Line LEACHING LINE fVo. & Length of lines A int 1G� Total length/size{ � FILTER BED ri Distance to nearest: u Well M—""- ` Foundation ,moi C3 r Property`Line 18 SEEPAGE PITS 11 Depth , site 'i Number SUMPS Lt Distance to nearest: Well Foundation i Property'Line j DISPOSAL PONDS ❑ R ; 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 rPe neon 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 compensa- tion taws of California." The applicant must call for all required insAections. Complete drawing oh reverse side t Signed v .Title: ---' �[r�'x� - _ _ --- Date: ,.• i ' FOR4DEPARTMENT USE ONLY Application Accepted lay Date Area �� ! .� QI Pit or"Grout Inspection bye- ` Date Final Inspection by Date 3�� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health i. Services, 'Environmental Health Permit/Services 1601 E. Rrzelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE OUNTDUE- AMOUNT REMITTED_ .`GASH - RECEIVEDBY, ,n�_,,,,_;DATE- .� - . PERMIT'NO...,,,. ... _ _. INFO + EH 13-24(14 EV.1/85) � � � EH 1 4.29