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i APPLICATION FOR PERMIT1 ' USAN JOAQUIN COUNTY' PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FRQM DATE ISSUED (Complete in Triplicate) Application is hereby [Wade 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. /J� s I qq 8 S /y /✓�^ ��l 4-5, City Lot Size/Acreage Job Address ! 0 Owner's Name �'`� �IVI � Address 4mdPhone33 s` ZO Z Contractor s �YS-S Address ed 05,N f License No. 77 _r Phone TYPE OF WELL/PUMP'. NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Dut of Service Well ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i.7 DISTANCE TO NEAREST: SEPTIC TANK /+� -__ SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Boitom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing rticfprlvare )9 Gravel Paffek L1 Tracy Type of Casing �`Z Specifications �-yFO — Cl Other I fl Delta Depth of Grout Seal eV— Type of Grout @�'r --: t ` Irrio.tion Z,4a-Appro'. Depth I I Eastern Surf�Ce1eal Installed by Cal&-�+�t TJX- - i epalr w one ❑ Type of Pump St's H.P. S �i( State Work Done- �' S �t Well Destruction ❑ Well Diameter Sealing Material & Depth Q t Depth Filler Material & Depth TYRE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I.l, (No septic system permitted if public sewer is }} J� \available within 200 feet.) Installation will serve: .Residence Commercial„_Other ff//` � �of livingunits:� "�- •`Number of,bedrooms ,Number Character of soil to a depth of 3 feet: '�'~� Water table depth SEPTIC TANK. ❑ Type/Mfg rCapacity No. Compartments PKG, TREATMENT PLT, ❑ ` � ” a .s" Method of Disposal Distance)to nearest: r Well f �Foundaiion Property Line LEACHING LINE Cl No. & Length of lines ; Total length/size FILTER BED 0 Distance)to nearest: 0 Well Foundation Property Line SEEPAGE PITSi I Depth IM .�t "'Size Number Sufi ps i l Distances to nearest:`k' Well Foundation Property Line DISPOSAL PONDS El .Iii 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 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 workmen'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 applicant must call for II re fired inspections. Complete drawing on reverse side. Signed X iLlifii7i i[.y I Title: dhAl_w^ Date: �I � ', .-DEPARTMENT USE ONLY q Application Accepted by ,_rv�(^^ _ Date _ -:r .- _l-�_----_- Area I Pit or Gro napection b Date c�_ Final Inspection b �, Date r Additional Comments: ` . AA licant �- Return all copies to: San Joaquin County Public Health C7 r2 QQ o`LOC?t t-�.�C.('--s-- J sci -+ t). D-t Services, Roviron cental Health Permit/Service�CA95�201 0f, ku f � &/0 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton l` 1 EEE AMOUNT DUE AMOUNT REMITTED CASH CK a RECEIVED BY DATE PERMIT'NO. INFO . EH 13-24 IpEY. i p 51 803 co1`l l ?�7 l q l f� o Q EH;1-2a =