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r APPLICATION FOR PERMIT .�.- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601T.E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t Application is hereby trade 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 1.862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Z-/ /.�a✓ �/�S/ AIAJy --- Cit 10 Lot Size/Acreage Owner's Name l�,etlow t aU Address S.A�E Phone -9r1- r ddress Aaw fty Contractar��°NF(.PE .0 //.C��1.lJ.fG[I�JL+R✓ _) License No,V, � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 1yZ/ DISTANCE TO NEAREST: SEPTIC TAN d SEWER LINES DISPOSAL FLD.N W_ PROP, LINE Pdd" T FOUNDATION AGRICULTURE WELL_ OTHER WELL PITS/SUMPSd� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private XGravel Pack ❑ Tracy Type of Casing lre- __ -_ Specifications t'1 Public 1-1 Other fl Delta Depth of Grout Seal I.JZ Type of Gro u A), I i lrrigallon .,._,_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done CI Type of Pump H.P. State Work Done — Well Destruction O Well Diameter Sealing Material & Depth a Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is l available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line 90 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size - - Number I SUMPS Cl 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, an 1 r rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not— employ omemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature 1 certifies the foilowing: "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 taws of California." Thyon s c 11 fo i requir d inspections. Complete drawing raverse side, k SigTitle Date: I OR EPARTMENT USE ONL fP Appted by Dates 0 Area Pit or Grout Inspection by Date--t Final Inspection by ( Date Additionaf Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 .:r a_ FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. -'i4;-EH 13.24IREV.I/n51 'EH"s{•Ia