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APPLICATION FOR PERMIT SAN JOAQUIN COUNTYvPUBL`IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON'AVE. , PHONE (209)468-3420. P O BOX 2009,'° STOCKTON, CA 95201 ` - ' `'PERMIT-EXPIRES 1 YEAR FROM DAIR ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County Por 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. .,p" /.�", ;. r, • „ „ Job Address 3016-2 City ✓ i�0"Y1Lot Size/Acreage Owner's Name 11 G Address _ Z _ej ' Phone f' Contractor w^rf� l( AdYess- _pP_Pr� l2a d—L4 the No. —� ri Phone I TYPE OF WELL/PUMP: NEW WELL.%_ _WELL REPLACEMENT-0 _ . DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE S".0 DISPOSAL FLM " PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL� PITS/SUMPS INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excav tion Dia Z Ch of Well Casing Domestic/Private F )L Gravel Pack^ - y-- - Type g ,.Specifications -.- I'] 'Trac . T e-of Casin �" _ - I'! Public Cl Other Cl pelta Depth of,Grout Seal (� " Type of Grout ! .-�.... Approx. Depth I J Eastern I Sud ace Seal Installed by Repair Work pone 0 Type ofPump•= H.:p._ Z, - State'Work--Dona T-t Well Destruction I❑ Well Diameter Sealing Material & Depth _ 11erNMeteria]. &`]7ep£h "' " De [h Yv Fi ' _._ p ... v TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/.ADDITION—I ) -'DESTRUCTION-I•'I Aft—septic system-permitted i#'public sower is available within 200 feet.1. 0 Installation will serve: Residence^'Commercial --Other Number of.living units: Number of bedrooms t, Character of soil tri a depth,ol,3 feet: Water table depth } SEPTIC TANK. 0 *jype/Mfg.,_ —"capacity "— - " __ No'Compartmeriis PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest; --`Well i Foundation 4T Property Line ► LEACHING LINE ® No. & Length of lines Total leiegth/size FILTER BED r CJ Distance to nearest: Well Foundation pProperty Line ] A. .r ! SEEPAGE PITS IJ Depth Sire. Number. SUMPS Ll Distance to nearest: ,Well Foundation' Property Line ' DISPOSAL PONDSi ❑ I hereby certify that I have prepared this application.and that the'work_will,be done in accordance with San Joaquin county ordinance ' rules and regulations of the San Joaquin County s, state laws, and Home owner or licensed agent's signature certifies the following: "I certify thet.in the performance of.the.work for which this permit is issued, f shall.not J employ any person in such manner as to become subject to workmen's compensation'laws of California." Contractor's hiriang or sub-contracting 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 compens - tion laws of California." _ _ The applican ust call or all re J'ed inspec 'oras. Complete drawing on reverse side. -- - ti:. Signed Date: Q ro. OR..DEPARTMENT.USE ON Application Accepted by Date.....: 1 b r d rea Pit o G ut l speetion by Date" Final Inspection by Data Additional Comments: _ �� c Applicant - Return all copies to: San sequin 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 f- INFO CASH IT RECEIVED BY DATE PERMN0. t, a EFF 13-24 IREV.I/X 51 3�t t7� 3� (� ._. -.-.._ _ EN 14.28 � b- O�b �O '�� S -7 W e