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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 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to Sari Joaquin County for a permit to construct and/or install the work herein described. This application is made In compliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t� 1 Job Address �7 Z s�iA�If7Eie _ I�J� City � 1�L Lot Size/Acreage .� Owner's Name A e k Address Phone FLm 3�1� Gonttactor^ _1rtJ0e117 -Address-7 /V. .��EL/3��T----a--�--License No. Phone 39-ZZ - TYPE OF WELL/PUMP:. NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL'S OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well-Excavation Dia. of Well Casing I Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Pnblic is Other fl Delta Depth of Grout Seal Type of.Grout t I Irrigation „_Approx. Depth I 1 Eastern Surface Seal Installed by— Repair y Repair Work Done 0 Type of Pumpi H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is A r* available within 200 feet.) Installation will serve: Residence Commercial— Other' oN'-� F Number of livingunits: , r`tP�4e �� S' _._.�_. Number of bedrooms�-. Character of soil to a depth of 3 feet: 1 0—L -7 Water table depth SEPTIC TANK. ❑ Type/Mfg L _ R-4-L Capacity 1_1-00 ,._.No. Compartments PKG, TREATMENT PLT. ❑ —, — Method of Disposal Distance to nearest: Well �_ Foundation Property Line LEACHING LINE C1 No. & Length o 'nes .Total length/size FILTER BED ❑ •Distance to nearest: Well oundation Property Line VVV t SEEPAGE PITS 11 Depth �, �• Y Si: _ ''"N-umber i SUMPS Cl .Distance tornearest; el! dation wProperty Line 1 DISPOSAL PONDS ❑ N I I hereby certify that I have prepared this applic ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin,c ty - 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 i 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." I ` The applicant must call for all required Inspections. Complete drawing on reverse side, Signed J Title: �`4atLc� ` Date: _ `T"/• -4 Z. ! FOR DEPARTMENT USE-ONLY Application Accepted by Date 7 ��- Area 7_1q t Pit or Grout Inspection by Date Final Inspection byziuzDate -74 CZ_ Additional Comments: &fX _ Applicant - Return all copies to:* San JPublic County Health Services, Environmentsl'Health Permit/Services 11601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 No INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 1 PERMIT'NO. OD . EH 19-74iRFV.I/n51 fl �l�� f/Z! I ( �s/ �e7�✓. EH 445