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�� APPLICATION FOR PERMIT I lL SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVICES h ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , `PHONE (209)468-3420 . P O BOX 2009, STOCKTON, CA 95.201 iPERMIT EXPIRES 1- YEAR FROM DATE ISSUED (Complete iW Triplicate) Application is hereby made,to Sa.n{joaquin County for a permit to construct and/or install the vork herein described.5 This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Qr; Job Address Z20Z S /Z City sCdN Lot Size/Acreage d�AC Owner's Name _r;4,V ' '� y t g Address t• Phone Contractor &; rd Q`3 _Address License No, 773t-r—PhoneN3 t- 4y7'-r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION PK SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 - DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD, PROP. LINE z � FOUNDATION AGRICULTURE WELL OTHER-WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f. 0 Industrial ❑ Open Bottom ❑ Manteca Dia`-of Well Excavation Dia.of Weli Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing vL Specifications I'l Public ¢ (_1 O � fl Detta Depth of Grout Seal Type of Grout I I Irrigation .Approx. Depth l I Eastern Surface Seal Installed by /f L Repair Work Done U Type of Pump �� H.P. State`Work_Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth 1�] E Depth Filler Material V Depth .Ti =; 1 TYPE OF SEPTIC WORK: -NEW-INSTALLATION"17- EPAIR7ADDITION=1.1j,..DESTEWCTION I I INo septic system permitted if priblic sewer is 'y # = aiailablewithin 200 feel l� ! 4 Installation will serve: Residence ' Commercial_ Other f I Number of living units: Number of bedrooms --• �_ ,__ Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK. ❑ -Type/Mfg*l Capacity x"`- No:Compart7r�ai►ts - PKG.TREATMENT PLT. 0- -. Method of Disposal Distance to nearest: Well Foundation Property Line ` r r i� it•�� 1 LEACHING LINE i 0 No. & Length of lines Total length/size'^ �a FILTER BED k 0 Distance to nearest: Well Foundation 'Property Line SEEPAGE PITS 3 11 Depth Size Number y `j SUMPS LI Distance to nearest: Well Foundation Property Line ' t✓ �, DISPOSAL PONDS: D kt h 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 owneryor 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-cbntracting signature 6 certifies thelollowing: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus (call for all required inspections. Complete drawing-onreverse side. 1 V Signed x-_sJ � Title: Date: -y+ FOR DEPARTMENT USE ONLY r t fes' Z _ I r Application,-Accepted by Date Area ____..___�.� Pit or G� rou Inspection by Date F- al Inspection by Date Additions Comments: f }- Applicant = Return all copies to: San Joaquin County Public ealth Iv ` 00. ; t r Services,_ Environmental-Health Permit/Services ; ? --x-1601 E. Hazelton Ave., P 0 Box. 009, Stockton, CA 95201 _ .I �� \ .a L �` .11.. �S lhr�t7tiC1 x , IFEE NFO AMOUNT DUE AMOUNT REMITTED CASHCy * , { '"RECENE6)BY �} ' �DAkTE�� PERMiT'NO. Es;1 z4fREv.,,es1 EH!4 �3� �3 r-. Za V G: 9�