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s APPLICATION FOR PERMIT SAN JOA..QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRQX DATE ISSUED t (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 sad Regulations of San Joaquin County Public Health Services. Job Address ,7514 til 09 A t l TE L- L,J City rKw� Lot Size/Acreage Owner's Name P-IL 4L' /-'/-Z,60t' --- Address C 1 rl ' Phone_ a Contractor F 12 111IngZ Ad4•ess .finiz[.Rei�r 4/—; i c e n s e No.Tf 1-S'y 6 Phone "-4`7 g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (l DESTRUCTION ❑Out of Service Well PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER O Mon4tcring Well O tP DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEwAAREA CONST UCTION SPECIFICATIONS (l Industrial ❑Open Bottom ❑Manteca Di oC Well Excavation Dia.of WON Caainq r Domestic/Private ❑Gravel Pack 0 Tracy ype of Casing- Specifications I'1 Public 17 Other (l Delta Depth of Grout Seal Type of Grout _ I I irrigation Approx. Depth I I Easter Surface Seal Installed by Q Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing r terial A Depth " 1 Depth Filler Material i Depth r(r TYPE OF SEPTIC WORK: NEW INSTALLATION Of REPAIR/AOOITION I I DESTRUCTION I I INo septic system permitted it public sewer is y avasablo within 200 leet.l Installation will serve: Residence_n/- Commercial_ Other ; Number of living units / Number of bedrooms _ Character of soil to a depth of 3 feet: /-�y Water table depth SEPTIC TANK ❑ Type/Mfg U Y (� Capacity 1 2�'o No.Compartments 2 p PKG.TREATMENT PLT.❑ Method of Oispoul3 Distance to nearest: Well_ _!v_1fL- Foundation 7t Property Line Yo LEACHING LINE C1'No.&Length of liner ?"- {�f r Total length/size 1" c'7� FILTER BED ❑ Distance to nearest: Well Foundation 7�1 Property Line SEEPAGE PITS I 1 Depth _}1 Size ��= Number SUMPS LI Distance to nearest: Well v7M Foundation 1411 ' Property Line m DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stJ.ndlaws, 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,1 SMB not employ any person in sucn manner as to become subtest to workmen's con.pensation laws of California."Contractor's hiring Or subcontracting signature Certifies the following: I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's c " Y De P Y 1 ofl11perlM- tion laws of California." The applicant must call for all required insMtctions.Coornplete drawing on reverse side. a; r Signed K� h- Y Title: f��' Data: � '-�� t /al � FOR DEPARTMENT USE ONLY C� Application Accepted by�\.�� <_� Date - Area �� k it Grout Inspection by rT Date "1 3� Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 S. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNTT D�U)E AMOUNT REMITTEO CASH RECEIVED BY DATE PERMIT-NO. - .FN 11124 IIIEV.,ixe, Nv �n Q ��3�f 11� 03.1 EH 111.21 w 12