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APPLICATION FOR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3.601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 f 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/.'' D� Job Address � � b - _ - l E"3Y��los N✓ _ City ISSCa(u.A Lot Size/Acreage Owner's Name [7r Qi06'5P 1('6- Address Phone Contractor Address License No. Phone -TYPE OF WELL/PUMP: --NEW-WELL ❑;:• WEL-L-REPLACEMENT ❑, DESTRUCTION '0 Out of,,Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑. Monitoring Well La DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED U'SE TYPE OF WELL PROBLEM AREA CONST.RL'1CTION SPECIFICATIONS Cl Industrial CI Open Bottom ❑ Manteca Dia--of Well Excavation' Dia. of Well Casing 9 1.1 Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications 4 I'1 Public is Other (-1 Delta Depth of Grout Seal Type of Grout I i Irrigation �.,Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done E7 Type of Pump H.P. State Work Done T Well Destruction O Well Diameter sealing Material & Depth Depth Filler Material L Depth I _ TYPE OF SEPTIC WORK` NEW INSTALLATION. REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sawer is 4 available within 200 feet.) Installation will serve:�,Residence Commercial Other — IF`f{ Number of living units: !. Number of bedrooms1- F. ..... Character of soil to a depth of 3_feet: �� _ __�.r��TYl . Water table depth SEPTIC TANK. Type/MfgJ ,tL Capecity � No:-Compartments PKG, TREATMENT PLT. ❑ Method of Dis�osat Distance to nearest: Well G23 Foundation ND Property Line ac� i _ ^ f LEACHING LINE ANO. & Length of lines . -_ rri — L{O Total length/size FILTER BED FI Distance to nearest: Well .T_- Foundation P9 Property Line b _ . :: SEEPAGE PITS 1'I j3epth �3 .�.Size � X � Number SUMPS ti. Distance to nearest ' Well l f? Foundation Property Line F 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 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: "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." The applicantmust call for all requr d iinspections.,Complete drawing on reverse side. i y Signed Title: Y Date: z ' FOR DEPARTMENT USE ONLY Application Accepted by V� Date 2. "CJ. Area Pit or Grout Inspection by Date Fine[ Inspection by� C.3 Date _ Date —Leper Additional Comments.- Applicant omments:Applicant - Return all copies to:. San Joaquin County Public Health Services, Environmental Health Permit/Services, 1601 E. Hazelton Ave., P1, ox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMtTTED ASH RECEIVED BY DATE PERMn'NO, —. ._ i . EM 73"24 IREV. Q�l� EH 71.26 U,.90