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� I 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 I� PERMIT EXPIRES 1 YEAR FROM-RATE ISSUED 1 (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 Joaquin County Public Health Services. Job Address 20gfV 6Im City 1r0 12 Lot Size/Acreage Owner's Name-Am m 42 I'd LLIgt�11.a� Address 0yy%P-_ Phone Contractor AddressG __ License No. �s�� Phone 36orw TYPE OF WELLLPUMP:a NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well 0 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack M Tracy Type of Casing Specifications V1 Public FI Other fl Delta Depth of Grout Seal Type of Grout i I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done CJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth f TYPE OF SEPTIC WORK; NEW INSTALLATION 147 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is �� A available within 200 feet.i Installation will serve: Residence` Commercial— Other +�' �c. � �� 7a S/� Number of living units: —IL- Number of bedroo s__ Character of soil to a depth of 3 feet: �!', Water table depth SEPTIC TANK. W Type/Mfg4 _Cc A�C � _ . -Capacity.._ I tri No. Compartments PKG. TREATMENT PL7. a § t t Method off Disposal Distance to nearest: Well�� Foundation �Q Property Line r r r LEACHING LINE LW _No. & Length of lineslength/size— FILTER f 3 Total length/size FILTER BED ❑ Distance to nearest: Well ,?_C1 r Foundation s` Property Line SEEPAGE PITS I I Depth Size _ Number p SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS -Cl - 7 a 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 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 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." The applicant u$t all for all requi d iqospactions. Complete drawing on reverse side. Signed Title: . 0GC)Ak# _...._ t Date: 7-7—P6 FOR DEPARTMENT USE ONLY t v �? I Application Accepted by Date T Area—7-1-3, Pit or Grout Inspection by Date Final Inspection b. 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 2909, Stockton, CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMITN0. r,hs, 1 �� .D C7 ( � •D� 3t?© �-Id�� `10-07 r /'