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APPLICATION FOR PERMIT � 4,07- SAN ,0SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OAC 06COI-r> ENVIRONMENTAL HEALTH DIVISION PR 10 2 9 7 L L1( �("1 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 Public Health Services. Job Address ��f X tIA L ed P,", City s-r74,,0 Lot Size/Acreage X 2-3 j Owner's Name t/g-=n 15V.-W7-10 Address Phone Contractor EL D,YD GakOO_Q Address --7 ADFtB�.GT.�r/� License No. Zd�7-Ile Phone'3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU W OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS C1 Industrial O Open Bottom ❑ Manteca Dia. of 11 Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cast Specifications I'I Public Cl Other n Dolt Depth of Grout at Type of Grout (� I I Irritation _.Approx. Depth 11 stern Surface Seal Install by Repair Work Done U Type of Pump H.P. ate Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms -S Y Character of soil to a depth of 3 feet: L-A Z Water table depth SEPTIC TANK ❑ Type/Mfg X t S 7'/AJ6 Capacity No. Compartments �1 PKG. TREATMENT PLT. ❑ Method of Disposal '1 Distance to nearest: Well Foundation Property Line LEACHING LINE L*T No. & Length of lines .� �� Total length/size e FILTER BED ❑ Distance to nearest: Well Foundation Z C Property Line 3 Q , SEEPAGE PITS Depth -Size" f� Number SUMPS LI Distance to nearest: Well J e;C2 Foundation 100-tt- Property Line Z-V 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, 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 applicant must call for all required uiinspectio ns. Complete drawing on reverse side. Signed Xs '� Title: Lt_ Date: FOR DEPARTMENT USE ONLY C� + Application Accepted by 4 Date e-5 — C Area I I ( - �� r In ., -[� Pit Or Grout Inspection by Date Final Inspection by� 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH EN 3+ . (REV.1/95) K_ . l � S. lG 3 A EH 7124