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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 O SOX 2009, STOCKTON, CA 95201 ,I EXPIRES I. YEAR FROMDA TE 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address CityQArWLot Size/Acreage &d '2.?6?g _ Owner's Name&, L&1 _..�._.. AddrressY Phone '6S Contractor L I/ PV4- Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ , SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 1s n Industrial ❑ Open Bottom ❑ Manteca Dia. of WeII Excavation Dia.of Well Casing 9 CI DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'i Public C7 Other ' F1 DeltaDepth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump ' yH.P. State Work bone Well Destruction ❑ Welt Diameter Sealing Material & Depth Depth Filler Material & Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION Pt REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X_ Commercial Y____ Other Number of living units: _L Number of bedrooms Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK A Type/Mfg 1 V&-e,,,Caitzrd&Capacity 12DQ _ No. Compartments � PKG. TREATMENT PLT.❑ OF Method oft'Diposal I / Distance to nearest: Wel! /h 0 ! Foundation /6 - Property Line LEACHING LINE No. & Length of lines. - 6 1'$ 3] Total length/size S FILTER BED C7 Distance to nearest: Well r<In Foundation _ /0 _ property Line y SEEPAGE PITS 11 Depth 91 _ Size Y'?"" ___, Number 31 SUMPS JA Distance to nearest: Well /_. 6 Foundation 6S r 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 persona subject to workman's compensa- tion laws of California." The applicant ust call r II req 'ted inspections. Complete drawing on reverse side. Signed X Title: Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area C Z �/,/ Pit or Grout inspection by Date Final Inspection b Data Additional Comments: /,. Applicant - Return all copies to: San Joaquin County Pub is Health r Services, Environmental Health Permit/Services p 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 t INFAMOUNT DUE AMO/UNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. . EH 13-241AEY.iin5i F{Oq} ! l/ f ® O jI'�7�`r�00 3EH 24-20 F