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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 RERMIT 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �•`�� City ^^ � MIA, �� s Lot Size/Acreage Owner's Name X41—F�� {�C sA Address ^1I Q I � � ''�� r _ R'6 Phone rjL"dL �(5 i Phone Contra Address _License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications U1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.- Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction O Well Diameter s` Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION K DESTRUCTION I I (No septic system permitted if public sewer is available vpithin 200 eet.1 Installation will serve: Residence Commercial_ Other Number of living units: Number of "drooms Od Character of soil to a depth of 3 feet: Water table depth U SEPTIC TANK. )9(- Type./Mfg ;Gapacityj_�QQQ -_ No. Compartments PKG. TREATMENT PLT. 0f r rf Method of Disposal {� j Distance to nearest: Well Foundation � '1 Property Line r ' LEACHING LINE 0 No. $ Length 6f lines I Total length/size FILTER BED 0 Distance to nearest: W611 Foundation Property Line SEEPAGE PITS 1 ) Depth___ m_ Size Number SUMPS GI' Distance to nearest: Well Foundation - Property Line. DISPOSAL PONDS I O . 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 . I — Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not z 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for squired inspections. Complete drawing_on reyerse.si Signed X - -.. Title: �/r ' _ Date: FOR DEPARTMENT USE bNLY y - Application Accepted by Date Area _ . Pit or Grout Inspection-by Date Final Inspection by TSt 7v Date Additional Comments: Applicant Return all copies to: 'San-Joaquin County:Public Health i Se'rvices,'Environment rllI alth Permit/Services t' 1601 E. Haaelion Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . fy1'.20inIEV.iyas) 3��/'9a o�� f