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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 BOX 2009, STOCKTON, CA 95201 i EXP RES 1 YEAR FROM DA ED (Complete in Triplicate) I Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein described. This application is made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules end Regulations of San Joaquin County Public Health services. .� City L/,(1 1.0t, Size/Acreage /14 Z x Job Address Phone 2,?Owner's Name E Q .7— S FLS / Address /11. LOX 3 Contractor iF� Y� F-, t000� Address ,q PA E,--T License No. ��xy�� -Phone S 3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION ❑ Out of service Wall ❑ PUMP INSTALLATION ❑ SYSTEM REP R ❑ OTHER 0 Monitoring We ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION GRfCULTURE L OTHER WELL INTENDED USE TYPE OF WELL PROBLE REA NSTRUCTION SPECIFICATIONS Dia. of Well Casing f7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T e of Casin Specifications [-i Domestic/Private ❑ Gravel Pack'°'�� 0 Tracy Type g Type of Grout 1 I'1 Public Cl Other F1 Delta Depth of Grout Seal l i I Irrigation Approx. Depth I 1 Ea ern S ace Seal Installed by H.P. State Work Done Repair Work Dane U Type of Pump Sealing Materi & f3epth Well Destruction ❑ Well Diameter / Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (Noseplic\e ws slemin 200 r itted if public sewer isavailabt Installation will serve:' Residence Commercial— Other 7— 19.7-e- Number of living units: Number of bedrooms" � - _ - ,- -� - �._ Character of soil to a depth of 3 feet:. r1 4 Water to a depth .C I 7 CJ No. Compartments �` « SEPTIC TANK D Type/Mfg'sC.e;^ p a"L Capacity ❑' � '-� , Method of Dispopal PKG. TREATMENT PLT. i aypistani a to nearest: Well 7 S Foundation 10 Property Line 7s, - t Z u ;- Total-length/size !-701 LEACHING LINE No. & Length of lines z r i _ FILTER BED ❑ Distance to nearest: "Wetl Foundation /� Property Line SEEPAGE PITS I1 Depth Size Number � SUMPS LI Distance to nearest: Well 100 f Foundation !�LV Property Line 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 t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature i 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 applicant must call for all required in/slpe�ctioonsComplete drawing on reverse side. S7-' �` Signed X � ' _ Title: Date: ` � g R DEPARTMENT USE ONLY Application Accepted by Date Area Date Final Inspection by Data Pit or Grout Inspection by 2� 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO • EN 1324(REV.a/n 5S a 0 EH 342E