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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 BOM 2009, STOCKTON, CA 95201 PERMIT EMPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City oeEf Td��_ Lot Site/Acreage Owner's Name -- Address r Phone Contractor /I z J5 1 ' ddress F,6, License No.��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 171 Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 11 Other • - -n Delta Depth of Grout-Seal Type-of Grout I I Irrigation _..Approx, Depth t I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material.& Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION I 1 iNo septic system permitted if public sewer is N available within 200 feet.1 Installation will serve: Residence-AE' Commercial_ Other Number of living units: —/— Number of bedrooms 43 Character of soil to a depth of 3 feet: ,4 / 44&x2r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE 79 No. $ Length of lines � t'O FT Total length/sizer FILTER BED ❑ Distance to nearest: Well ¢ Foundation r Property Line SEEPAGE PITS 1 1 Depth Size x Number SUMPS Ll Distance to neatest: `Well Foundation 4 Property,Line DISPOSAL PONDS p = '. 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 cartifies'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 its issued, I shall empWy persons subiect to workman's compensa- tion laws of California." The applicant must scall for regquu d inspections. Complete drawing on reverse side. Signed X ` C -I�t�� Title: _ &lk M a d r Date: FOR PART 4T USE ONLY - i Application Accepted by Date c Area i Pit or Grout Inspection by Date Final Inspection bir 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 95201EE I INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE �' t PEAM11'NO. EM 13-24 IREV. b � EW'4.267_70p © rj