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I I! li APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ` P 0 BOX 2009, STOCKTON, CA 95201 PEUIT EXPIRES I YEAR FROM DATE ISSUIED (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 vith San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San :f Joaquin County Public Health Services. I Job Address I I 1 City Lot Size/Acreage 8dX 3ALL I i Owner's Namey/d 1 5'Q'Q U P Address - Phone Contractor_ E! c_ �l> . Lr/ayo Address 7 Al. At*License No. Phone -A¢ TYPE OF WELL/PUMP: ill NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.Well Casing C.l Domestic)Private 0.Gravel Pack ❑ Tracy Type of Casing Specifications F] Public I.1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done_ Jr Well Destruction ElWell Diameter Sealing Material & Depth LA D p1h Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is I� -/ available within 200 feat.I Installation will serve: Residence V Commercial_ Other Number of living units: _- r- Number of bedrooms_,? Character of soil to s depthi1of 3 feet:._ -. LA,Y Water table depth SEPTIC TANK © I Type/Mfg _. -.1p`if"�— Capacity / o No. Compartments 2- PKG. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation 8B Property Line LEACHING LINE No. & Length of lines - �S Total length/sire l A Foundation ' FILTER BED _ ._ ❑ Distance to nearest: Well AJ Foundation v�-S " Property Line SEEPAGE PITS, 11"" Depth Size Number SUMPS LI Distance to nearest: Well N2f► Foundation . loQ/' Property Line DISPOSAL PONDS ❑ 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 i 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 shall not employ any person in such manner as to become subject to workman's comperisation laws of California." Contractor's hiring or sub-contracting signature j certifies the following: "I certify that in thYerformance of the work for which this permit is issued, I shall employ persons subject to workman's componsa- f tion laws of California." '11i. t The applicant must call for all'required inspections. Complete drawing on reverse side. l Signed Title: Date: 7;„21 fFOR DEPARTMENT USE ONLY � Application Accepted by- I! Y y ��j � Ci _ Date S 2 - _-c { Area l f Pit rFGrout Inspection by Date �'�`� Final Inspection by�}l ~�s Date I ` Additional Comments: II� Applicant - Return all copies to: San Joaquin County Public Health --• - `I Services, Environmental Health--Permit/Services-- r 1601 E. Hazelton Ave., P 0 Box 2009.,_Stockton,_CA.�95201 INFO FEE AJMOpUNT,�DVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t . EH 13-24IREV.iix51 S� 1►J .r Y 5/l� r�� L2.2-t-91 � EH 14-26 !r � , - -