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APPLICATION FOR PERMIT 7r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 1PHONE (209)468-3420 IP O BOX 2009, STOCKTON, CA 95201 NIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Applicat on is hereby de,to 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 I Joaquin County Public Health Services. �rk-ew_1 /Wlelcs-r SE D6F 1\101Z.71-1- 4 E�t� Jab Address ��—C 12 ! City Lot Size/Acreage Luc) _ Q � 1 Owner's Name Luc)f F�2ttilt" Address �. Z /1�t I�L()LA160 5'�k �l Phone f %9 r-C{V�' ContractorN0h%41Cn_9CO Address (JC�QL L�,� ['l�t/T License iVrn✓056c) �s Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEMA REPAIR ❑ OTHER © Monitoring Well �� I -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �M DISPOSAL FLD. PROP."LINE FOUNDATION AGRICULTURE WELDd OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of C.a`sing Specifications 1`1 Public C] Other Cl Delta Depth of Grout Seal Type of Grout 4i.r 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump :5 H.P. I� State Work Done _ Well Destruction ❑ Wel! Diameter Sealing Material & Depth,. 9 l Q Depth' f Filler Material![& Depth TYPE OF SEPTIC WORK; NEW INSTALLATION # I REPAIRIADDITION i I iDESTRUCTION I 1 INo septic system permitted if public sewer is r available within 200 feet.) t Installation will serve: 'Residence— Commercial_ Other y ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' r Water table depth '� l SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT.❑ r , 1., Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines 1M Total length/size FILTER BED D Distance to nearest. Welt Foundation Property Line SEEPAGE PITS I ) Depth Sire 1� Number SUMPS C! Distance to nearest: Well Foundation r» Property Line DISPOSAL PONDS 0 1 I hereby certify that I have prepared this application and that the work will be d6rte 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 inI a 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 N 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 mus I for al! re wired in �cttions. C plate drawing on r r Ill. Signed X Title; .., �.(�/ Date: i `FOR DEPARTMENT l!USE ONLY Application Accepted by I Date 7 �S Area 2—1'12— Pit 2Pit or Grout Inspection t Date Final Inspection by Data -� Additional Comments: ,y 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 j[ FEE INFO AMOUNT DUE AMOUNT REMITTED CASHCK I RECEIVED BY DATE PERMIT NO. . EH 132 IItEV.Finso �'00J Mg '--ry., 1� —ro EH 7�•2e ( 91 ! r