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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 kEM11 EXPIRES 1 YEAR FROM DATE 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 ` r Q EE � City--5' �-�(�'t� Lot Size/Acreage Owner's Name St LV I ON I C-0(2 Address 5 fa ME Phone j 13 Contractor Ak ACY, Address 4ZO E EgfMLAUL�_IV License No.1504/_03 Phone 2ft?l/ TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well. 0 PUMP INSTALLATION Y� SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications !'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I Irrigation —_Approx. Depth t I Eastern Surface Seal Installed by Repair Pump sState _ � y� Well Destruction O Well Diameter ling Material & Depth 0Lf1' 0 / 1,10/-QJ fJ'rZ-L Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well f=oundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and 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 sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call for all required inspection Complete drawing on vers side. 17/Signed X-- �� Title: &=L,..�113.`^�`�-� Date: `��- FOR DEPARTMENT USE ONLY //��,, Application Accepted by Date-._ ` 4 Area Pit or Grout inspection by Date Final Inspection by G Date ZJ� 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 IFEE O OUNT DUE AMOUNT REMITTED CK CASH RECEIVED 6Y DATE PERMITN0. e EH 13-24 MEV.I/)q 51 Pl: too 3� C� 1'Z EH 1425