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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / Y - ENVIRONMENTAL HEALTH DIVISION 1601 E HAZELTON AVE. , PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 ` %P RES I YEAR FR M D TE 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J [ Job Address of City c Lot Size/Acreage l `lam C- Owner's Name C_r,�D I In 4k j am Address _1 7f_ g L_�f (9 1/� �=c^l _ Phone Contractor 1 ` 6 lnl i Address_p k '.". !l License No. 9q-TS 3 Phone_ `0 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION 19, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD.Z-_" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom 0 Manteca Dia. of Well Excavation pia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I'1 Public 1.1 Other f 1 Delta Depth of Grout_Se ,__ �C� Type f Grout k ellemsIn-el r I I Irrigation en-21.Approx, Depth I I Eastern Ar rface Seal Installed by _(�! ,�iZr , r,_Cr Repair Work Done L3 Type of Pump H.P. .7 /� State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l lnstallation will serve:_Residence-Commercial.----Other. N Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 T /Mf yPe g Capacity No. Compartments PKG. TREATMENT PLT, L] 7 4 cif Method of Disposal € Distance to nearest: Well Foundati/oh Property Line LEACHING LINE ^Cl No.,& Length of lines Total length/size Vx FILTER BED k 0 Distance to nearest: Well Foundation Property Line 1 i SEEPAGE PITS .1.1 Depth Size Number 1 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I heieby 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 .r Home owner or licensed agent's signature candies 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "l,cerdfy 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." i The applicant must call for all required inspections_Coxnplete drawing on reverse side. ; r Signe X Title: C S- I Date: R DEPARTMENT USE ONLY I _� - --- -- Application Accepted by Date 2L ! Area Pit c Grout I pection by Date- Final Inspection by Data_! -15 T Additional Comments: ` L E Applicant - Return all copies to: San Joaquin County Public Health 1 Services, Environmental Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 t1 1 t INFO AMOUNT DUE AMOUNT REMITTEO CASH RECEIVED BY DATE PERMIT NO. pt a EMI 3.24 1REV.7/x5) EM -2a b [