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! APPLICATION FOR PERMIT I it SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 i P O BOR 2009, STOCKTON, CA 95201 0a EXPIRES 1 YEAR FROM DATE TSSU (Complete in Triplicate) work in Application is h�eebinmade omplianan ce vithuSSanCJooaaquin Co tyrordinanceconstruct No. 549and/or 1862ins and theeRules and Regulationsaof Sans application is Joaquin County Public Health Services. SL �CTgkJ Lot Size/Acreage l�o E M'� C� `�'TC� � city /Areae I Job Addres ZP IM c L�IGET (�r4L/U(JT `KBE CQPhane Owner �5733 ' f'rOf`-tCE Address Owners Name _ sf�77 KTvxsi �—Phone g f I Contractor Address E��S ! t RT`� L'scense No. 6S TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT 13 DESTRUCTION ❑ put of Service Well ❑ ll' OTHER 2� monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -sem„ SEWER LINES O� DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK -- PITS/SUMPS FOUNDATION — AGRICULTURE= WELL OTHER WELL—• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ID Manteca Dia. of Well Excavation A-- Dia. of Well Casing 7 T e of Casin vG Specifications C_1 Domestic/Private ravel Pack L7 Tracy Yp Casing—p of Grou F�rT i'1 Public #-1 Other F1 Delta Depth of Grout Seal -�Q I I Irrigation 9 Appfox. Depth I I Eastern Surface Seal Installed by ri7i IE - I p State Work Done _. Repair Work Done 0 Type of Pump Sealing Material & Depth Well Destruction ❑ Well Diameter p�T (adr t Depth Filler Material & Depth //IJEa S YPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR�ADDITION l I OESTRUCTiON I i availableNo se �wthin 200 feestem t.) if public sewer is _ I ' ^Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth:iof 3 feet: # Capacity No. Compartments E SEPTIC TANK ❑ ,Type/Mfg Method of Disposal € PKG. TREATMENT PLT, 0 %1 [Distance to nearest: Well Foundation Property Line k SII r LEACHING LINE ❑ I`No. & Length of lines Total length/size FILTER BED CI " Distance to nearest: Well Foundation Property Line SEEPAGE PITSI I I`Depth Size Number � SUMPS Ll ilDistance to nearest: Well Foundation Property Line k DISPOSAL PONDS C1 ii rk will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the wo 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 shalt/not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub contracting signature certifies the following: "1 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 o alifornla." The app c u all for all requir in pections. Complete drawing on reverse side. ZO /� Signed Title: + �� w" .TF- �N �" Date: SII FOR DEPARTMENT USE ONLY �^ — Application Accepted by Date Area �`'Lv t I _.Final.Final Inspection by Date Pit or Grout Inspection by Additional Comments: I� 1 :�. Applicant - Return all copies to: San Joaquin County Public Health I Services, Environmental Health Permit/Services 'I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE " CK RECEIVED 8Y DATE PERMIT"NO. INFO AMOUNT DUE AMOUNT REMITTED CASH a EH 13-24(AM a� EH 94.25 V a p