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APPLICATION FOR PERMIT 4. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE, , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES ]: YEAR FROM DATE ISSUM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork 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 _ -_ S �l� [r►'� - _— City tf✓�! __ Lot Size/Acreage Owner's Name \.!r pn t S f c Address �4 vv, Phone Contractor <, -f Address jpa Ivftse < License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service .Well �1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial • ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing � Specifications I'l Public C7 Other 11 Delta Depth of Grout Seal Type of Grout 11 t(rigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done [J Type of,Pump H.P. State Work Done _ Well Destruction "❑ Well Diameter Sealing Material & Depth " Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION I i INo septic system permitted if public sewer is S available within 200 feet.) v\ Installation will server Residencet! Commercial Other Number of diving units: I Number of bedrooms 3 1 Character of soil to a depth of 3 feet: s 0 7 Water table depth SEPTIC TANK. Type/Mfg 4- L- 59 AlL e- ,'Capacity LID No. Compartments PKG. TREATMENT PLT. ❑ t f" Method of Disposal Distance to nearest: Well _., Foundation . _ ", Property Line LEACHING LINE VZ & Length of lines 3L4D Total length/size FILTER BED ❑ Distance to nearest: Welli r ?)D+. Foundation �� Property Line SEEPAGE PITS L4'Depth f Size_ 3 Nlmbgr SUMPS Ll Distance to nearest: Well - I5D% Foundation 50 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 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." The applicant must all for all squired inspections. Complete drawing on reverse side. - Signed X— _ Title: _-�' ''�" Date: FOR DEPARTMENT USE ONLY �+ l Application Accepted by C Date / � � Area�LZ PJyelr Grout Inspection byr~ ate `�� JFinel Inspection by T��/�/zi�'�'a1e� � Additional Comments: Applicant —Return all copies to: San Joaquin County Public Health Services, Environmental-Health Pdrmit/Services 1601 E. Hazelton Ave., P 0 ]lox 2009, Stockton, CA 95201 FEEkNFO AMOUNT DUE AMOUNT REMITTED CAIn SH RECEIVED BY DATE PERM17'N0. . EH 13-25 IREV. 51 �! r/ 11 q EH 14-25o/ 1r `t �