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i APPLICATION FOR PERMIT SAN JOAQUIN' COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O. BOX 2009, STOCKTON, CA 95201 . RIi1IT EXPIRES 1 YEAR FROM DATE- ISSUED `` (Complete in Triplicate) Il 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 r ity TiieAC Lot Size/Acreage C Owner's Name �• ��pr 1�— Address Phone E f Contractor L %Ve `'� Address �, ZfY m r_!�A License No a Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f') Public fa Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation __Approx.1Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work pone_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth T Filler Material & Depth 3 TYPE OF SEPTIC WORK: NEW INSTALLATION bd REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is ! available within 200 feet.) Ur Installation will serve: Residence Commercial Other Number of livingunits: ' Number p} bedrooms y L: k Character of soil to s depth of 3 feet: 4 O�� %9/H Water table depth SEPTIC TANK ❑ Type/Mfgt_ - _- Pk Li capacityodf�� No. Compartments I PKG. TREATMENT PLT. ❑ �� Method of Disposal Distance to nearest: Well /07J Foundation_s d Property Line 'T LEACHING LINE No. & Length of lines, - 3 F7 Total length/size _� FILTER BED _ ❑ Distance to nearest, Well g! Foundation �'� �T Property,Line �U r SEEPAGE PITS l I Depth { � Size "" "--Number .' SUMPS Distance to nearest: Well iQl�p Foundation!Q_ Property Lines�� ,k" DISPOSAL PONDS ❑ I hereby certify that I have prepared this 7application 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 7 _ 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 , f 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 forwhich-this permit is issued, I shall employ persons subject to workman's compensa- E tion taws of California." - V The applicant must call Boor all re ,red ins coons. Complete drawing on reverse side. e- - / Signed Title: Date: _t �f fo i OR DEPA-RTMENT USE ONLY-- d • " F Application Accepted by Date Area Pit 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 i . INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED By DATE PERMIT•NO, EH13-24 1REV.t/x SI i t fes' 1 f EH 14.29 �Q ., - l �t Li/ 4 p 1.20A.