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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-8420 P O BOX 2009, STOCKTON, CA 95201 !I+ PERMIT EXPIRES 1 YEAR FROM 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 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 �T OtJ o. E-mvieRx Rd . CityLaufflopLot Size/Acreage 93 Owner's Name MONT IS I i 1 C rR Lit- Address I d04 E• fD 1-50N. M/QRITIEW44ne 8 { Contractor Atom ST--, Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service':.Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring-'Well ❑ l 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications C1 Public fa Other fl Delta Depth of Grout Seal Type of Grout i I Irrigation _._Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H-P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.► Q Installation will serve: Residence �L Commercial____ Other Q r Number of living units: _� Number of b drooms Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK Type/Mfg b C CapacityApAd.a No. Compartments , PKG. TREATMENT PLT,-0 Method of Disposal Distance to nearest: well FoundationJr ^_ Property Line _ LEACHING LINE W—No. & Length of lines tq['� Total length/size FILTER BED ❑ Distance to nearest: Well O d Foundation 200 Property Line. 400 � SEEPAGE PITS I 1 Depth Size Number SUMPS LI 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 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 T 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 call for all required insPections. Complete drawing on reverse side. 3,- Signed Title: (')1A 24AS6 Date: _7 ^ 2-7;-90 ' F, DEPARTMENT USE ONLY q Application Accepted by v ��, �uv�hr, .�,,_,,,.,,, Date 7/3 c) !b ea Pit or Grout inspection by Date Final Inspection by Date Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE[ INFO AMOUNT DUE AMOUNT{i$MITTEO CASH RECEIVED BY DATE PERMIT'NO. . EH171-Ze 3-20(REV. FH r/K 5) 1 -7=3o 1.V—0 I-