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' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 2` ,f 1601 E. HAZELTON AVE. ,, PHONE (209)468-3420 P O 'BD% 2009, STOCKTON, CA 95201 �f EXP RES 1 YEAR FROM DATE ISStBP � (Complete is 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 1 Zai owo&/ City�X Lot Size/Acreage ' + Owner's Name gA"`0 -Address - Phone a Contractor �A rass � �� License No. B Ac Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl out of Service Well ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR G OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK I Ga 0 SEWER LINES DISPOSAL FLD. PROP. LINE ALJ 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 (A/Domestic/Private L1 Gravel Pack r ❑ Tracy Type of Casing ' Specifications f'I Public [_1 Other rl Delta Depth of Grout Sea! Type of Grout I I Irrigation ._.._..Approx. Depth OgEastem Surface Seal Installed by ` Repair Work Done ❑ 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 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence lk Commercial— Other A k Number of living units: - Number of bedrooms :3 ^ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 11 Type/Mfg L Capacity_ No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Q Foundation Property Line 3 . LEACHING LINE CI No. & Length of lines Total length/size - FILTER BID F1 Distance to nearest: Well�! Foundation `f O Property Line ate SEEPAGE PITS I I Depth ��i___-_Size,`� �14 1d Number SUMPS Ll Distance to nearest: Well Foundation; Property Line t 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 Joaquin County t 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 Mtm call for all required inspections. Complete drawing on reverse side. Signed Title: Date: -!a-1 J-60 P W OR DEPARTMENT USE ONLY Application Accepted by 4. �pa - Date ` '`-O Area t Pit or Grout Inspection by Data - Final Inspection by Additional Comments: Applicant - Return all copies to: Saa 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 CIC RECEIVED BY DATE PERMIT N0. INFO CASH r EH 13-241AEV.r/x51 !I f[ �.� / 'f, (�� —(,S— k r"GL '-' 7 t7 � ��(� 1 EH 14-M