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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 Zapplication 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 `� � __ �- ` -�A /� _ _ - City Lot Size/Acreage 10 �_ ft F �1 'y n Owner's Namec", � � Address .64 CID� ,A 1�� L Phone"3116-01- 190 Contractor ` r Aail 6 Address Mo bi 30 [�- License No.'32?'z �- Phone b -S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service .Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAAESV SEPTIC•TANK'"` SEWER LINES DISPOSAL FLD. .PROP.-LINE , FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wail Casing Cl Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications I'I Public I-i Other ❑ Delta Depth of Grout Seal Type of Grout t 11 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 Seal*ng Material & D,epth r Depth Fi11er Material TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I ] INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resridence Commercial T Other Number of living units: ___L__. Number of b r _oma Character of soil to a depth of 3 feet: Water table depth Q } l SEPTIC TANK Type/Mfg `� Capacity No. Compartments V PKG. TREATMENT PLT. ❑ ( / Method of Disposal Distance to nearest: ,Well 5-04- Foundation -d__ Property Line - /f ... LEACHING LINE No. & Length of lines "r Total iengthlsize O FILTER BED Cl q Distance to nearest: WeII= Foundation_/0 Property Line _ SEEPAGE PITSSize Number SUMPS CI Distance to nearest; WeII, Q +' Foundation .Property Line . .: 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 Joaq- 6iti County i' Home owner or licensed agent's-signature certifies the"following:%'A certify that in ths,parformance of the work for which this permit is issued, I shall not employ any person in such manner as to become.subjecrte workman's-compensation,taws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this perm_it is issued, I shall employ persons subject to workman's compensa- tion laws of,California." y �:• ___. ,,; ��. The applicant m'v call for aR-requiroid inspections. Complete drawing on reversersi- 't Signed X Title: Date: FOR DEPARTMENT USE ONLY ` r� Application Accepted by Date 2 Area 1 L 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 CK a RECEIVED BY DATE PERMIT NO. + EH 13.24 1rtEV,t i K SILl EH 74.26 �/ + b o O s h I