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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES vD ENVIRONMENTAL HEALTH DIVISION i 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 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 *cork 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 Service/s.� ��J �/ Job Address `�� 14-) t�t�&4tf 'f, r%tel City 06't A Lot Size/Acreage =IA-e, Owner's Name �� Address u Phone 36 033 Contractor, ✓ Yea Address +�� License No.2�9,r7�l Phone TYPE OF WELL/PUMPS NEW WELL ❑ WELL REPLACEMENT FJ 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 6� n Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public CZ Other Cl Delta Depth of Grout Seal Type of Grout I # Irrigation —..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material i Depth / I Depth Filler Material b Depth" TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION [,-I DESTRUCTION I I (No septic system permitted if public sewer is f r available within 200 feet.) Installation will serve: Residence Commercial ___ Other '* r Number of living units: Number of b r mei _ �3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. i R- Type/Mfg - '�,(�� Capacity C20 No. Compartments Z PKG. TREATMENT-PLT, ❑ p Method of Disposal Distance to nearest: Well Foundation �_ Property Lina -in LEACHING LINE E'lr No. & Length of lines 3 OI _ Total length/size Q FILTER BED Cl Distance to nearest: Well,-l� f Foundation- Property Line f SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line I 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 taws, andw ruies 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." The appZM7:2�= rawing on reverse side. /� ASigned Title: -_.6_,0�Cli _. _ Date: � O �� 7 U v FOR DEPARTMENT USE ONLY Application Accepted by _,_a Date 10—/te7—'7U Area Z_ 3 k Pit or Grout Inspection by Dates Final Inspection byDatAU- tit 4� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Peralt/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIT"NO. e EH 13-24 MM€/n sl 1 Y r!'7. � � � � � �{y,r� ]� L� -.?b j C, EH 14-26 (V Gw n !