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y APPLICATION FOR PERMIT 3 Of) j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 p O BOX 2009, STOCKTON, CA 95201 PFMIT EXPIRES 1 YEI FROM DA2:,U 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 i Joaquin County Public Health Services. Job Address _ oR�D R� City _5' Lot Size/Acreage ZGZ S32- Owner's Name (j/2- }0 E Address SA2V 4 Phone 97x3-�r�22- 74 Contractor_ FL.[�'1.f� U®D—Address r 4 License No. 5�2.�Y7G Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT E.1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ , OTHER ❑ Monitoring Well DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing f Cl Domestic/Private ❑ Gravel Pack C1Tracy ry Type of Casing Specifications I'] Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout 1 I Irrigation y _.Approx. Depth I ) Eastern Surface Seat Installed by Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction C1 Well Diameter Sealing Material 8 Depth ! Depth Filler Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I_. REPAIRIADDITIONDESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) - 1 S Installation will serve: Residence_A /Commercial_ Other l Number of living units: T-I— Number of bedrooms ., - .. Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Y Capacit �.A Nb. Compartments �' PKG. TREATMENT PLT. ❑ _„ ' ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines 'fid _.__ Total length/size 1 j _ s FILTER BED � [:1 Distance to nearest: Well .._dW r Foundation 3 D � _ 'Property Line /go, � SEEPAGE PITS 11 Depth _ 2_11L Size ,�� --Number Property Line P S SUMPS Ll Distance to nearest: Well�1�_ Foundation R 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 I 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 of 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 must call for all required inspections. Complete drawing on reverse side. l Signed (/I/YTZI'�j Title: Date: -- I FOR DEPARTMENT USE ONLY j Application Accepted by Date Area j Pit or Grout Inspection by Data Final Inspection by Date l Additional Comments: Applicant - Return a3.1 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 4 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 k FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. INFO f Q + EHt3-241R EH 94.25 EV.rin5l �t\ �l / �� s / / ` 111 s