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/ r r APPLICATION FOR PERMIT ;f I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION if . 3-601 E. HAZELTON AVE. , PHONE (209)468'-3420 �- (J P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM ATE ISSUED (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 coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules &ad-Regulations of San-- Joaquin County Public Health Services. Job Address ( /j City 061 Lot Size/Acreage.AZL1/L) eA 04,L, Address ((4 /l Alr 13GAS-r - Phon7 J-17.� Owner's Name Contractor RI b ?f"r� Address - License No. �b�Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEM NT ❑ DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well f DISTANCE TO NEAREST: SEPTIC TANK,./000 SEWER LINES 7LO OD DISPOSAL FLDZIODO PROP. LINE ZLL � FOUNDATIONl f AGRICULTURE WELL, OTHER WELL J PITS/SUMPS1UWO .-. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y f1 i F industrial Open 9ottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Cas g ['I_Domestic/Private --Cl Gravel Pack C3 Tracy Type of Casing 5mkt-- G -- Specificatiops 3-'1 Public Cl Other - n Delta Depth of Grout Seal Type of Groulm � 1p� Irrigation 3- Approx. Deptly I 1 Eastern Surffaacce, Seal Installed by ' Repair Work Done U Type of Pump H.P. State Work Done Well Destruction D" Well Diamet _. Sealing Material & Depth Depth Filler Material & Depth � I TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other � 1 Number of living units:' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ iType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED # 0 Distance to nearest. Well Foundation Property Line �n 1 SEEPAGE PITS 11 Depth Size Number q SUMPS D Distance to nearest: Well Foundation . --- Property Line !I DISPOSAL PONDS 0 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 rn rules and regulations of the San Joaquin County 4 Home owner or licensed agent's signature canifies 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 Calif is. The applica t call for all req eienspe 'ons, Complate drawing on re a side. Signed Title: Date: I F D TMENT USE ONLY , Application Accepted by Date __�-�1 Area r Pit or Gro Inspection by �Datej � Final Inspection by `�r � — Date 3 S Additional Comments: 3 Applicant - Return all copies to: Joaquin County Public Health Ab Services, Environmental Health Permit/Services 16011. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ' 1)r/NFO CASH . EH 13-24 IREV-i i H 51 ^f P', �O I `� EH it-28 ,• �� 1/89