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APPLICATION FOR PERMIT ,� J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ti ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 pyJWIT EXP RES 1 YEAR FROM DAIR 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. &Z-A Lot Size/Acreage .7/Y xc_ Jab Address � � �/�/ Crty Woz)6&+ S_Vic '6��LF Owner's Name R 1 'SS N f AddressZE- y a"� Phone Contractor ;.FJ y(_ Address License No. 3 7"21 Phone,346 Qgf,?3 TYPE OF WELL/PUMP: m NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ ', PUMP--INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monito"ring Well [7 E � I DISTANCE TO NEAREST: SEPTEC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications c ( I'I Public Ia Other C-I Delta Depth of Grout Seal Type of Grout ) I I Irrigation ____-.Approx• Depth l I Eastern Surface Seal Installed by f Repair Work Done 0 Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material & Depth { l i Depth Filler Material & Depth E€ TYPE OF SEPTIC WORK: NEW INSTALLATION 1r REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted it public sewer is 11 available within 200 feet.) installation writ serve: Residence ' Commercial_ Other .J Number of living units: Number o rooms_1 - Water table de th Character of soil to a depth of 3 feet: - - p SEPTIC TANK CT-Type/Mfg _ ifJG'�= �� Capacity I No. Compartments PKG. TREATMENT'PLT:❑ dw Method of Disposal i Distance to arest: Well L r+ foundation � Property Line g� 114 LEACHING LINE Pr'No. & Length of lines Total length/size FILTER BED } ❑ Distance to nearest. Well -/4055 Foundation 7-4ir r Property Line 't. SEEPAGE PITS W,Depth ,oZ s Sill_ 3G r` h Number / SUMPS !ifl L'I Cpistancce to nearest: Well �� Four\ation�� _ _ Property Line 3S q \1 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-Joiaquin County 1 . X Home owner tit licensed apent_s.signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any person inesuch 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 performancejof the work far which this permit is issued.I shall employ persons subject to workman's compenss- `,,,pion laws of California."' I Thg'pplic st,cafl for allreq ed i pections. Complete-drawing-on-reverse-side. Signed rX /~ Title: - dGt�.T.r y Date: FOR DEPARTMENT USE ONLY li n Accepted by �� v Date t✓ Area f Pity r Grout Inspection by �l +<�- �� Date la Final Inspectio b - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health -- - Services; Environmental-Health Perrr[3 t/Services 1601 E. Hazelton Ave., P,fOS "20a9,`Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. � INFO f Q C� f , . EH 13.24(REV.r i H 5) t7 I r r 3 1 f�7 D `'7- b-9 L. C,- l T-7 Eli 14-M s