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01 r APPLICATION FOR PERM IT ► SAN tJIOAQUIN COUNTY PUBLIC HEALTH S ICES `k ENVIRONMENTAL HEALTH DIVISION 1601 T. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 RMIX RES I YEAR FRQM DATE ISSUED (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. nn y � Job Address __- 26 ,-__ Se.T.1-i �-__1'tLCQP__r 11 3 City LA +-� _ - Lot Size/Acreage Owner's Name d`�'�� 1 ti't-' Address Zb51 �CX,_T i Hn rz a Phon�741 - 7M 140 2 r ContractorC '_Vr%34) Address* -e r�1-e Licen e No. `(3Phone 6 -4126 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR '0 OTHER ;2e'- Monitoring Well (3 �c lu..+c , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 40-EL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Z ,lnjcrrLi Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -__ _/ __-_ Specifications- - Il Public I"1 Other D-0alla Depth of Grout Sea! S FE�7— Type of Grout &r1 MAJ, TE r I I Irrigation ?.Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H,P. State Work e _ Well Destruction ❑ Well Diameter Sealing Platerial & Depth S• Zic� wtk Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNa septic systern permitted it public sewer is available 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg apacity No. Compartments PKG, TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE 0 No. & Length as Total length/size FILTER BED ❑ Dlstanc nearest: Well Foundation Property Line SEEPAGE PITS I Depth Sire Number SUMPS Lt Distance to nearest: Well Foundation Property Line DISPOS ONDS I hereby certify that 1 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 must call far a!t required inspections. Complete drawing on reverse side. Date: Lt t 7 - Signed Title:FOR DEPARTMENT USE ONLY f,/ Application Accepted by Data` `�! �� Ares Pit or Grout Inspection by ate — incl In;pe lion bcy c Date Additional Comments: Applicant - Return all copies to. San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton. CA 95201FEE INFO CpyAMOU/Nr�T DUE AMOUNT TT]REMITTED -9CASH RECEIVED BY f DATE 9PEERMIT'N'gO. . EH13.24(Rev.I/it$I v�� V J350� EH 14.76