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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 O 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. f j� �i Job Address Z?5z/7 5, ', tom"`' y City�� Lot Size/Acreage �/U A. Owner's Name &tdz /,,,—4E1,�y Address / s, //f.Qd� iqy Phone `3 Contractor Address f License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring WPLI ❑ 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 , C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' (•I Public Ll Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth ,t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION 1-1 DESTRUCTION I 1 INo septic system permitted if public sewer available within 200 fedt;:J Installation will serve: Residence Commercial-___ Other Number of living units: _L_ Number of bedrooms 21 ,t A N Kw 1, 1 % .1 f Character of soil to a depth of 3 feet: gf table depth SEPTIC TANK W1 Type/Mfg taigacity Nd Compa tgrt►eel PKG. TREATMENT PLT. ❑ " NSetoc�,�jf; `spcl M Distance to nearest: Well � Found iolp� �; Gtlo tint' LEACHING LEACHING LINE No. & Length of lines Tyl length/size 1 FILTER BED 1-1 Distance to nearest: Well _ Fountjption O Property Line T _. r SEEPAGE PITS 11 Depth Sizer Number t `; SUMPS LI Distance to nearest: Well Foun "',fin-- ---, PSVperty Line DISPOSAL PONDS ❑ c ' `= *" '"•e"°` I hereby certify that I have prepared this application and that the work will be done in acdbrdance with San Joaquin county ordinances, state IaWs, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the perfIrrhance of the work for which this permit is issued, I scall not employ any person in such manner as to become subject to workman's compensation laws�ot California." Contractor's hiring or sub-contracting siinature certifies the following: "I certify that in the performance of the work for which this permit i"af ssued, I shall employ persons subject to workman's cortipensa- tion laws of California." 7t The applicant uSt call rallmuired in pections. C mplete drawing on reverse tide: Signed X Title: _//�/ /L'.tDate: R DEP MENT USE ONLY .8 Application Accepted by Date /'W/�, �o 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 13-24IAEV.vnsl EH:1.26 14 :7j= -3 '0(-)-:7/-r G Oi6Li O