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/v APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM D ED (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 trade 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 1 d /V /4" - City Lot Size/Acreage Owner's Name �. t✓�^^ L03�TEJ7t � Address Phone Contractor 'A - !-l(G�G` "i__ -_-Addresspo — License Nov6� Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. 0 PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well L� DISTANCE TO'NEAREST: SEPTIC TANK'- SEWER LINES" ' _ DISPOSAL FLD. ' PROP. DNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— M Industrial C7 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing f7 Domestic/Private ' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public i-1 Other 17-1 Delta Depth of Grout Seal Type of Grout I i Irrigation _____-Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material & Depth Depth Filler Material & Depth J TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O �� '` available within 200 feet,) Installation will serve: Residence_'r Commercial Other Number of living units: I .i Number of bedrooms�— Character of s*it to a depth of 3 feet: +ooh. AA/��C Water table depth SEPTIC TANK �© Type/Mfg - Q� G• Capacity A600 'L No, Compartments PKG. TREATMENT Pd. ❑ 17 Method of Disposal r ! Distance to nearest: Well 1G1Foundation �y Property Line ha�r" LEACHING LINE ,f No. & Length of lines, Total length/size • t/-rJ FILTER BED EI Distance to nearest: " Well 0� Fourtdation��_ Property Line 1b SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation 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 fol 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 call for all r uir d inspections. Complete drawing on reverse side. Signed XTitle: .-•�r Date: YFOA DEPARTMENT USE ONLY rt Application Accepted,by r Date Aran .211-6 Pit or Grout Inspection'by , "Date Final Inspection by ate .5` 6 Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2D09, Stockton, CA 95201 IFEE AMOUNT DUE - AMOUNT REMITTED CASH.. _CK If RECEIVED BY DATE PERMIT'NO. . EH 13.24 IREV.1/14 si I EH i4"26