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APPLICATION FOR PERMIT SAN} JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION T 1601 E. HAZFLTON AVE. , PHONE (209)468-3420 AV P O BOX 2009, STOCKTON, CA 95201 Zqi� . FEB [� - E%P RES 1 YEAR FRQM DA E ED SAN.103AQ!,1 N CULPdTy (Complete in Triplicate) PUBLIC HEALTH SERVICES Application is hereby made to San Joaquin County for a permit to construct and/or installE VIRONMENTork n describDIVISION s application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address z5�� - eeuc Tt-atr< S�j ��-� City LST �/- Lot Size/Acreage / 19Ce15 Owner's NameNtr5T3Address -5�1�� / d ��,,��pp - --/—, . �....�' T: ! Phone h Ca7tractor _ <.•,�� r Address 0 - � - - i7 erase No. -5 Phone��/Ea t 2�Z7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ;PUMP INSTALLATION,0 ` 4 SYSTEM REPAIR ❑ t OTHER ❑ Monitoring Well DISTANCE TO NEAREST;)SEPTIC TANK /U,4,, SEWER LINES d` DISPOSAL FLD, NA PROP. LINE>0 FOUNDATION AGRICULTURE WELL A-'14 OTHER WELL NA PITS/SUMPS N INTENDED USE ° TYPE OF WELL per; PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( ] Industrial '❑ Open Bottom Manteca Dia. of,Wsll Excavation D I �/ - _ Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type pf Casing ✓Ci t� f.� Other Specifications- I 6'I Public S --- f( Delta Depth" Grout Seal Type of Grout.f,- g2yT �a0 I i Irrigation — Approx. Depth I I Eastern Surface Seal Installed by /U:Pq [ /N JLY=' ` sl Repair Work Done ❑ Type of Pump H.P. State Work Done Wel! Destruction ❑ iWell Diameter Sealing Material & Depth Depth Filler Materiel 6 Depth j TYPE OF SEPTIC WORK: ; NEW INSTALL4TfON ! I REPAIR/ADDITION i I DESTRUCTION I I lNo septic system permitted if public sewer is �'S Installation ll r available within 200 feet.) ,Installation will serve: Residence_ -_ Commercial Other i Number of living units: t Number of bedroom's - * � Character of soil to a depth of 3 feet: SEPTIC TANK - Water table depth ❑ Type/Mfg — r A No:Compartments . PKG. TREATMENT PLT, ❑ > RECEIVED $ Method of Disposal �# Distance to nearest; Well.—I Y r Foundation Property Line -1000 t i LEACHING LIN):.. ❑ No. $-L'ength of lines ({� length/size FILTER BED l ' ❑ Distance to nearest; i Well— UBL1�2"EAI0'�1F3_Sl=�i+Vl('•F� Property Line `" ENVIRONMENTAL HEALTH DIVISION SEEPAGE PITS', t)-' Depth Size f t' Number I ' SUMPS r 11 Distance to nearest: Well ( .�} Foundation r. Property Line ' DISPOSAL PONDS 1- L7 .:-. I hereby certify-that I have prepared this application"and that'the v), rk.will be done in accordance with San Joaquin county rules and regulations of the San Joaquin County ordinances, state laws, and¢ , Home owner or licensed agent's signature certifies-the following: "Il'Certify-that-in the periormance-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 subcontracting 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 t call for all re uired ' pections. Complete drawing on reverse side. Signed ` Tide: Date: DEPARTMENT USE ONLY _-- Application Accepted by ` Date Area Pit or Grout Inspection by_ Date J . ��z Final Inspection py_ Additional Comments: _Date Applicant - Return all copies to: San Joaquin County Public Health T Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ,J FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY ` CASH ` DATE PERMI7'NO. EH 14-25IAEV.r/rf5i A //�/�� A , . / 9�j EH 14-I5 ` fjyy�/ //V,/yi'. v1—fill- I�d ✓ —�l'./✓t� -)