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�I I APPLICATION FOR PERMIT SAN JOAENQUIN V RONMENTAL HEALTH DCOUNTY PUBLIC IVISION ON TH VICES SCANNED 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate). Application is hereby made to Ban 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 L- fi _ City fYZ c=n,,.. H ` Lot S12e/Acreage Owner's Name 1C_yL/✓j Address Phone Contractor 11,A1. /L t` f: Address �—�U, /l;- �"/i '�� License No,�'i Phones 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 Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — F] Public C.1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump M.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTIOW4 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: _,L- Number of bedrooms Character of soil to a depth of 3 feet: '�.A + , Z,]r1 A'I - Water table depth SEPTIC TANK ❑ Type/Mfg r�`,f4 Z11 Capacity /-��%gin No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE Ck No. & Length of linesf Y _ Total length/size FILTER BED Cl Distance to nearest: We- FILTER FT Foundation PT Property Line f,',1 SEEPAGE PITS 11 Depth % Size I.Q u ,< ��y y Number � SUMPS �L Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for a required Inspections. Complete drawing on reverse side. Signed X g L/< - Title: (E.. _t l.�.��. Dale: -: - / FOR DEPARTMENT USE ONLY _ Application Accepted by /yJ/ L�L� � Date ' l S Area - Pit or Grout Inspection by Date Final Inspection by - 1.=��- (--' Data Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED _ CASH- - RECEIVED NY DATE PERMIT NO. . EM 1324 IREV.iixm -- EM A