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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1. YEAR FROM DATE„ISSUED r (Complete in Triplicate) a 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 Servicers. I If r 1 /} r .fob Address 87 7l F- :fes G City Lot Size/Acreage Owner's Name __—�___r� / re� / J / , �i1, Phone Contractor Address - License No. _- -/—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l7 DESTRUCTION ❑ Out of Service Well ❑ 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 I n Industrial © Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications E I'] Public # 11 Other -1 Delta Depth of Grout Seal Type of Grout i i I Irrigation —Approx..j Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diametei Sealing Material Depth Depth 1 Filler Material & Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I l lNo septic system permitted if public sewer is �-5 available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: -I— NumfI ofedroo s 3 _ Character of soil to a depth of 3 feet:, (Z 4e% Water table depth CJ SEPTIC TANK. ❑ Type/Mfg Capacity CV No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ZZO r Foundation Property Line- 7 r LEACHING LINE Q,-INo. & Length of lines Total length/size r. FILTER BED f ❑ Distance to nearest: Well aO f Foundation 0 E � � Property Line SEEPAGE PITS IV Depth T f _Size_ A (0 � _ Number 3 SUMPS LI Distance t+o 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 for which this permit is issued, I shall not employ any pers?n,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 all for all requir ins tions. Complete drawing on reverse side. Signed Title: �e p Am Date: i; FOR DEPARTMENT USE ONLY �r A plication Accepted by Date l�:A— �� LU Area �-- l Pit r Grout Inspection by r �� Dale- { `� Final Inspection bY�C� Date U Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 FE CK f INFO AMOUNT DUE ' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-21(REV.Ii It 5) 3 (r'� 7^c ` F EH 74-2e LJ ( ( G V