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APPLICATION FOR PERMIT l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PEMIT RXPIRES 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 glade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. c Job Address `��"+ I f1 f�' ��T�, T City -r' ML— Lot Size/Acreage / Af eA Owner's Name UL f el` i.7tf eNC SfMP-A3—AddressS' �C ^J� vrr� Phone Contractor :b Address License N . �a Phone TYPE P P� Y E OF WELL/ UM NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Sery ce Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitor ng Nell 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 I n Industrial ❑ Open Bottom ❑ Manteca .Dia. of Well Excavation Dia. of Well Casing S Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications'' 11 Public Ll Other 171 Delta Depth of Grout Seal Type of Grout = I I Irrigdtion .-.._,.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Dane_ 4if .11, ; Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__.._. Commercial_ Other j Number of living units: 1 Number of bedrooms 2 { Character of sail to a depth of 3 feet: 7� Water table depth SEPTIC-TANK. ❑ Type/Mfg V Capacity�ZQr2 No. Compartments Z— PKG. TREATMENT PLT. ❑ t Method of Disposal 3 D Distance to nearest: Well S Foundation .�_ Properly Line 1Q D LEACHING LINE 31�_No. & Length of lines Total length/size IF I FILTER BED- Cl 'Distance to nearest: Well Foundation Property.Line SEEPAGE PITS t l Depth x-5 Size 3� _ Number 1 SUMPS , , LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and y rules and regulations of the San Joaquin county Home owner or licensed agent's signature cenifies 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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." 1 The applicant I Aal , quired ' pections. Complete drawing on reverse side./ /� Signed X Title: ` Date: 2 Z ' - i R DEPARTMENT USE ONLY �1 Application Accepted by Date Lf d4� Area % Pit or Grout Inspection by fn\,. Final l,sp ction by Hate Additional Comments: P�LI'ne uwdw� . Applicant - Return-a11 copies to: San Joaquin County Public Health t!15 r�� --q�--q � Services, Environmental Health Permit/Services r r �f t jr-� �ayvu ^ 1601 E. Hazelton Ave., P0 2009, Stockton, GA 95201 F't FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT'NO. H �[�&f EH *26 iREV.I i n 5r EN A�I-26 F�