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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUBP (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. 1 Job Address ! ,R U�� City Lot Size/Acreage Owner's Name f ..jE-17- m 9-PML Address I a86$1 Gel - 6 Xle Phone �4 F Address License No. Phone_ Contractor , TYPE OF WELL/PUMP: -NEW WELL ❑ -WELL REPLACEMENT_❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION ,AGRICULTURE WELL,. OTHER WELL. PITS/SUMPS z INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial Il Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public C7 Other n Delta Depth of Grout Seal Type of Grout I # Irrigation —.Approx. Depth I ) Eastern 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 I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION { I DESTRUCTION l I (No septic system permitted if public sewer is OD available within 200 feet.) Installation will serve: Residence_ Commercial— Otherto tLE ONE: S'�TLG Number of living units: Number of bedrooms f 1" l r�{p�u �+� t T SDP A-CCES�a All kD IS�E Character of'soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ _ 10-d-fes Method of Disposal Distance to nearest: Well /M::E- Foundation= --� Property Line LEACHING LINE ❑ No. & Length of lines 1 -75�`V I"�a r Total length/size - FILTER BED LI Distance to nearest: Well rV'D+ Foundation Property Line SEEPAGE-PITS 11 Depth Size Number SUMPS. LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ w r 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 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, l 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 ust 11-for all required inspections. Complete drawing on reverse side. Signed L Title:- Date: T''5 R DEPIkRTMENT USE 91NLY Application Accepted by24Date I Area /6 Pit or Grout Inspection by Date~� Final Inspection by Additional Comments: 7 W y r r f ' Applicant - Return all copies to: San Jos uin County Public Health H Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. J r EH 13-24 TREY.1)KSY 4� 470 1913 t� -� a/ 7 d 90 �Za F EH./-2E