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APPLICATION FOR PERMIT /4�JSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 PublicHealthServices. Job Address T�?L� Al, .GLIM /. City 1-47 / Lot Siz Acreage Owner's Name `U•L' _L,�.f/6� Address S'i4JtlE Phone Contrattor 1XFi�i/P tthV&] Address _7 Al. License No. ��-S'�-76 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. or-woo Casing.,_} E) Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications �J I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by .� Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.)' Installation will serve:. Residence I/Commercial, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: GL A)e Water table depth SEPTIC TANK. O Type/Mfg L Capacity 4V© No. Compartments Z PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well /04 Foundation Property Line Z O LEACHING LINE No. & Length of lines .3 60 Total length/size C7 FILTER BED O Distance to nearest: Well !DD ' Foundation 1S` Property Line 6�al_ SEEPAGE PITS I Depth 2Sr Size 4 Number SUMPS CI Distance to nearest: Well /SD, Foundation I S� Property Line 1470r DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit iti,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. Signed X Title: &21s _ Date: FOR DEPARTMENT USE ONLY Application Accepted by DateArea ` 2' j or Grout Inspection byi7.4Date �^' 'Final Inspection by Date.j&_� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health " >'- y Services, Environmental Health-Permit/Services \ .J 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EMI 3' Q z�(REV,l/n 51 / �,�f(� / yj Q D 3 3 / / / (f25 Q EH 14.