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+" APPLICATION FOR PERM I T SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAM 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin Countty/Public Health Services Job Address L Ls�J �i J � City Lot Size/Acreage Owner's Name!�1tl�Ley / ld©(Zf --- Address Phone 2 Contract L�,_4 ' P Address-P-0• t3" C l,f_P!4M License No_ZY2 Z CJ� _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ f 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C� Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications. -. I'} Public 0 Other Fl Delta Depth of Grout Seal Type of Grout I Irrigation —_Approx. D# I I Eastern Surfa(.Seal Installed by I Repair Work Done IJType of Pump �- H.P. ^ T State Work Done Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other A� Number of living units: Number of bedrooms 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: Well Foundation Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS L3 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 f Home ownea 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:fot wing: "I certify that in the pe or ance of a work for which this permit is issued, I shall employ persons subject to work an's/omansa- tion laws of lifornia." The appfica must call for II required ins ct' 6s.. Co plate drawing reverse side, Signed X ~ .Title Date: R DEPARTMErNT USE ONLY ] Application Accepted by Date r Area V Z + ''IV' Pit or Grout inspection by Date Final Inspection b7� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Envirotmmntal Health Permit/Servicea 1601 S. Hazelton Ave.. P O N09, Stockton, CA 95201 IFEE AMOUNT DUE AM NT REMITTED CASH ElVED 8Y DATE PERMIT NO.� • EH 13* 24(REV.i/Hsi r EH i4-26