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APPLICATION .FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION MACHADO 1601 E. HAZELTON AVE. , PHONE (209)46:8-3420 247 N..�aCDO INCRoad P O BOX 2009, STOCgTON, CA 95201 HERMIT EXPIRES 1 YEAR FROM DATE ISSUED Stockton, CaliforniarniA 95215 (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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public'Health Services. �-�/� Job Address ,��l.r? - _LSC.• - _ City5Y25:Y 5:* Lot Size/Acreage i Owner's Name , u C Address 15�o. Phone Contractor Addressr; �$! 2 License NOE522d Phone! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTIEl DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,` OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 0 DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL; 'PROBLEM AREA CONSTRUCTION-SPECIFICATIONS f n Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ./Domestic/Private G] Gravel Pack ;-, ❑ Tracy Type of Casing Specifications I'i Public (.1 Other Cl Deltadepth of Grout Seal Type of Grout I I Irritation .Appr6i . Depth l I Eastern Surface 5eai Installed by Repair Work Done Type of Pump , H-P. ' - State Work Done Well Destruction ❑ Well DiameterSealing Material & Depth' Depth Filler Material'& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms f" Character of soil to a depth of 3 feet: '�i p Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity 5 No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line � y LEACHING LINE CI No. & Length of lines Total length/size FILTER HED E) Distance to nearest. Well Foundation Property Line i SEEPAGE PITS 1 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ lr 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." Thescant t call for all req , ins pec ns. Co late drawing on reverse side. o •- k ` Signed Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date D Area i Pit or Grout Inspection by I Date Final Inspection by Date I Additional Comments: / Applicant - Return all copies to- San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO �AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, + EH CH A-221(REV.t i 8 51 7� ��( `1✓ Z b r70