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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P 0 BOX 2009, STOCKTON, CA 95201 PRUIT EXPIRES 1 YEAR FROM DATE ISSUJD (Complete in Triplicate) Application is hereby made,to Sas►,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. � n fd Job Address � t��v� City �CJ11J Z., _ Lot Size/Acreage w Phone Owner's Name l`9 6 j ( ._ Address Contractor 6 _ AddressJJ4:2� License No.306 7'21 Phone TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 ❑ Industrial ,/ 0 Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public CI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.tDepth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth i Filler Material & Depth J TYPE OF SEPTIC WORK: NEW INSTALLATION E7 REPAIR/ADDITION i I: DESTRUCTION l 1 (No septic system permitted if public sewer is 1 "r available within 200 feet.) c1�V Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C!?'r Type/Mfg Capacity .,7 4,Gr7 No, Compartments PKG. TREATMENT PLT. C7t y Method of Disposal `Distance to nearest: Y_ WeRI t Foundation �_ Property Line I 1 7 - LEACHING LINE P-' No. & Length of lines �_ �[ Q Total length/size /0 O FILTER BED ❑ Distance to nearest: Well f&0 Foundation ti/ Property Line3 6/Z , SEEPAGE PITS I I Depth Size . Number I SUMPS LI Distance to nearest: Well �L Foundation Property Line DISPOSAL PONDS ❑ !1 I -7 -- r - I hereby certify that I have prepared this aapplication and ttiaf the-work.will be�don`in accordance with San Joaquin county ordinances, state laws, and I 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 persons subject to workman's compensa- tion laws of California." I The applic t must call for all requi d in ctions. Complete drawing on reverse side. I Signed X� Title: ._.__r�W��J Date: c U FOR DEPARTMENT USE ONLY Application Accepted b,\ my � Date r U U Area I n�,- Pit or Grout Inspection by Date .Final Inspection by --�„ Date Additions! Comments: j Applicant - Return all copies to: San Joaquin County Public Health Services. Environmental Health Permit/Services i 1601 E. Hazelton Ave., P O'Box 2009. Stockton. CA 95201 FEE r INFO AMOUNT DUE ( AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT ND. r EH 13-24 IREV.I,HSI 1 , a-a , - , r e c�'-TD a r�7. . EH 31.241 - J