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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH-DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)46$-3420 - P O BOX 2009, STOCKTON, CA 95201 kI MIT EXPIRES_I YEAR FROM DAJE ISSUED (Complete in Triplicate) f 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 compli&nce with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 523.3 5' ZAQE L0 City 52?,tC 7dAf Lot Size/Acreage 457 Owner's Name Za-A 2 S�f��f1 _ Address i-0' 90 X &_/9 Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public CI Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation _____Approx. Depth I I Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material & Depth s: Depth Filler Material & Depth - �!a! TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 14- DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) }` Installation will serve: Residence_ Commercial— Other L 6'//. ,& IF 'p� Number of living units: 190 Number of bedrooms p Character of soil to a depth of 3 feet: E % + Cc- ` Water table depth OO SEPTIC TANK. R ,Type/Mfg Capaci U_Z5_11fW No. Compartments PKG, TREATMENT PLT. ❑ P Method of Disposal r' Distance to nearest: Well -170 Foundation l0 Property Line_ 5q:t LEACHING LINE f No. & Length of lines 4 9 '3 Total length/size- FILTER FILTER BED I?f Distance to nearest: Well /?,!:p 14V y Property Line !d� SEEPAGE PITS W Depth Size_ 5:'blA Number SUMPS LI"' Distance to nearest: Well -_70" Foundation .LD _ Property Line S� DISPOSAL PONDS ❑ tt 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 compensation 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 compensa- tion laws of California." 1 The applicant t calf for all tions. Complete drawing on reverse side. Signed Title: --.—-- �f?�/7?.1// W Date: F. DE MENT USE ONLY Application Accepted by Date Area / Pit or Grout Inspection by Date Final Inspection by 2 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 INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY. DATE PERMIT'NO. . EH13-TI[REV.tiKSI EH 74.2e �r�D t 0Q `�/ ` 8-3—2 c � o- 1