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ir APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P, O BOX 2009, STOCKTON, CA 95201 ,1 REMIT EXPIRES 1 YEAR FROM DATE , SSUED =.i (Complete in Triplicate) Application is hereby made.to Saiz 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 w. Job Address ty Lot Size/Acreage 0 dA A- Owner's N '.i rt 4 dress Phone Ir" Contractorame t4l7o,R/f>i4-aAddress License No. Phone 000 TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHERChMonitoring Well f, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �. f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom "D Manteca Dia. of Weil Excavation Dia. of-Welt Casing i f:] DortiesticlPrivate ❑ Gravel Pack_ 0 Tracy Type of Casing Specifications i'1 Public ,1-1 Other 11 Delta Depth of Grout Seal— Type of Grout I I Irrigation Approx,Depth I I Eastern Surface Seal Installed by Repair Work Done L3 .Type of Pump H.P. State Work Done � = � _. Well Destruction ❑ Well Diameter Sealing Material & Depth r O ' Depth • Filler Matiriiil &Depth' "'� TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted U public sewer is s r available within 200 feet.) y. _r Installation will serve: Residence Commercial__._._ Other i Number of living units: --I— Number of bedr oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 q Method of Disposal r/ F Distance to nearest: Well Foundation �7, Iv CY f — Property Line- � r�_D Ll' ) LEACHING LINE C1No. & Length of lines �- I Total length/size `I �4 FILTER SED-,-.. Cl Distance toi nearest. Well" ' CEJ Foundation- Property Line SEEPAGE PITS l I Depth KX22UTSI Number SUMPS LI Distance to nearest: W Foundation _ Property Line DISPOSAL PONDS ❑ 4 I hereby certify that I have prepared this application and that the-vvwk will be/done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the followingh certif ty hat in the performance of the work for which this permit is issued, I shall not rkman•compensation taws of California." Contractor's hiring of sub-contracting signature employ any parson in such manner as to become subjept to wo certifies the following: "I certify that in the performance of the wo ,far which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican si II II repair r speetiaris. tnpBrte7drawing on re rs side, Signed Title: Date: FOR DEPARTMENT USE ONLY / Applic n Accepted by Date Area .dction� cby ' n Date i /Final Inspection by rout Iv Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health 'Services, Environmental Health Permit/Services .1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO + rr U r� CASH RECEIVED BY DATEq PERMITNO. . EH A-24t31AEV.rinss 1 t.d (� ,(�3 EH.�-28 l v -