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APPLICATION FOR PERMIT �I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZTLTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 EMIT EXPIRES 1 YEAR FROM: DAJE 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. `` LJobdress 3 Qi 4 City _140 if- 0n Lot Size/Acreage •D gox SS5)� Y1 Z- Y'7s Name � 1 C O ` h Address Phonector l� L Address License No. PhoneOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP.INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I') Public t-1 Other (l Delta Depth of Grout Seal Type of Grout I i lrrigation — Approx. Depth t I Eastern Surface Seal installed by Repair Work Done L] Type of Pump H.P, State Work Done , Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION (,I DESTRUCTIONINo septic system permitted it public sewer is w ,. ', ,a_ available within 200 feet,) installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms R Character of soil to a depth of 3 feet: } Wa '' ter table depth SEPTIC TANK. O .Type/Mfg 4 i;_..: - - Uac._ No. Compartments PKG. TREATMENT PLT. ❑ T Method of Disposal erff day have expired without Distance to neares : e I F u anon, Property Lina completed or ins W LEACHING LINE ❑ No. & Length of liuirnnrrir' t7I NPaItE1 I length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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, andVY # 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 t certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California," Zigned applicant ust call for all requir d inspections. Complete drawing on reverse side. 1 Title: _f'1 UJ n f {� :Z_ ..„_. Date: -- FOR EP SE ONLY Application Accepted byr. A C L4 � •.. ._ Date Area 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 INFO AMOUNT�DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13-24 1REV.F i N 51 EH A-28 t l! C CJ C J 3 (3