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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 comliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. rr77 S�'�CTG�cJ ®¢G Job Address �� j-1_ City� TFx-1612 Lot Size/Acreage Owner's Name d�Sg/� C±A119aG L L Address ( �.t5 /- " /41, � Phone ConlracttirULLL?C Address POP Ztf E-stl9_--_- License No.�?'��1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE yJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottoms ❑ Manteca- iDia. of Well Excavation Dia. of Well Casing v D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public Cl Other n Delta"._ ._Depth of.Grout Seal Type of Grout r I i Irrigation .......Approk. Depth I I Eastern Surface Sedi installed by Repair Work Done 0 Type of Pump H.-P.. State Work Done _ h& D Seating Material Depth ' Well Destruction ❑ Well Diameter-.--: Sea - Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION>Q DESTRUCTION 1.1 INo septic system permitted if public sewer is 1 �available within 200-feet.) Installafion will serve: Residence Commercial` Other Number of living units: -/_.._ Number of bedroom` Character of soil to a depth of 3 feet: •a gz;7 q-^ ^Water table depth SEPTIC TANK ❑ Type/Mfg Yw�:Ci Capacity. ��bd No. Compartments PKG. TREATMENT PLT. G7 Method of Disposal Distance to nearest: Well D Foundation `30 Property Line LEACHING LINE D No." & Length of lines —2 7- /"f. Total length/size 7- :J f FILTER BEDCL Distance to nearest: Well Zl -�oF ation �� Property Line SEEPAGE PITS f`f Depth ;!2 6 F r Size_ 7 '_ Number 7 1, SUMPS 0 Distance io nearest: Well_9D t r-Foundation �r Property Line f DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work-will be,done-imaciordance-with•San'Joaquin county-ordinances, state laws, and j rules and regulations of the San Joaquin County Y 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for al required inspections. Complete.drawing on reverse side. Signed Title: --- r j Date: FOR DEPARTMENT USE ONLY Application Accepted by Date AA Area pe Y fi "f 1 91 Pit oY"Grout Tns etion l b Date Final Inspection by _ Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health - Services;, Environmental Health Permit/Services 1601 E.,,,Hazeltou Ave., P 0 Box 2009, Stockton, CA 95201 � _MFOI 'AMOUN/T�OtJE`^ AIiAOUNT'AEAIIITTEO— ,CASA fiECEIVEO BY . CH 13.21(REV.tins) FH 11.18 I 1