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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT-EMIRES 1 YEAR FRQM DATE ISSED (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. Job Address .2y` U �^ City � U p I Lot Size/Acreage Q Owner's_Name. /(�Y ls e_g_ 'c —�Address ,_ _ _ Phoned - t ��5 Phoe Contractor V - _._ Address' License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out oft Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I (J IJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS €] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack M Tracy Type of Casing Specifications) i.I Public CI Other n Delta Depth of Grout Seal Type of Groul i I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by t Repair Work Done U Type of Pump H.P. State Work Done I t ) Well Destruction ❑ Well Diameter Sealing Materiel Depth Depth Filler Material & Depth a U TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence— Commercial_ Other\ Number of living units: Number a bedrooms� �� +� I r Character of soil to a depth of 3 feet: 3" Water table depth .26 SEPTIC TANK. fW Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal �/� f 1 Distance to nearest:' Wel{�— Foundation /r� Properly Line I` LEACHING LINE Eq- No. & Length of line, CZ zoal 1 Total lerigthlsize 166.1 FILTER BED ❑ Distance to nearest! =Wenti Q r I Foundation 2 S } Property Line SEEPAGE PITS I I Depth Sized Number ' SUMPS L) Distance to nearest: Well— Foundation Property Line w1 DISPOSAL PONDS 0 ` r-4 I hereby certify that i have prepared this application ind that-the-work-will be done in accordance with San Joaquin county ordinances,Gstate laws, and rules and regulations of the San Joaquin County] fi Home owner or licensed agent's signature certifies the following: "I certify that in the performance of ihe-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 CalVfomia." Contra for's hiring or sub contracting signature certifies the following: "I certify that in.,the perlormance of the work far which`ithis permit is issued, l shell er nploy.persons subject to workman's compensa- tion laws of California." The applic st rcall for all re )red nspections. Complete drawing on reverse side. 1 Signed X I Title: 0Wved Date: �� ! Q FOR DEPARTMENT USE ONLY ! Application Accepted by�' 2;r5 , `- w ) Date l � ��'] Area 1 / Pit or Grout Inspection by Date p J T'r'"Tinal Inspection-ti I Dat �l j —Additional Comments: Applicant - Return all copies to: San Joaquin County,'-public Health:a, Services, Environmental fl`altli Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE 3 INFO AMOUNT DUE AMOUNT REMITTED QICK 113 RECEIVED BY DATE PERMIT'NO. . EH 13.24(REV.+/K5) -40- 0o -�-/y i} EH A-26 / 5