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APPLICATION FOR PERF I T SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 "'iJ P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 1§§UED (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. �� Q Job Address (6 )F, � �--- _:_ _ _ City Lot Size/Acreage s �� 1 7 3,9 Owner's Nam .�IILC Addressit^/� "[J ' Phone Contract I Address p� `License hio3Z92�L-L Phone —FIOST TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 n industrial ❑ Open Bottom ❑ Manteca Dis- of Wel{ Excavation Dia. of Well Casing [I Domestic/Private Cl Gravel Pack E) Tracy Type of Casing Specifications I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work pone U Type of Pump .H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material b Depth Depth ' Filler Material b Depth TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted it public sewer is 00000 available within 200 feet.1 Installation will serve: Re 'dance 2L Commercial Other Number of living units: Number of edroa s /057 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg Capicity` 4W No. Compartments PKG, TREATMENT PLT. ❑ f F t I f Method of Disposal OF Distance to nearest: Well Foundation Property Lin LEACHING LINE No. & Length of lines 3 Total length/size X FILTER BED Cl Distance to nearest: Well 709ZWounclation /_j2 Property Line y 6f SEEPAGE PITS Depth Size Number SUMPS Cl Distance to nearest: Well �� Foundation�'o o _ Property Line DISPOSAL PONDS o 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.:' Contractors 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 mu for all requi d VW4�,itlp, ns. Complete drawing on revers sSigned Date: R DEPARTMENT USE ONLY 4 � c� Application Accepted dby (�;;l71 " c� ,_2 Date �t��, Area Z Pit r Grout Inspection by �Yf't �r--� ' Date -5� 'Final Inspection by\�e �!�t Date Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH l3-Z4{REV.I/n sS EH 14.25