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APPLICATION FOR PERMIT k 5 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA_•95201 E "k,.PJMWIT BMIRES 1 YEARR`FROM DATB ISSUED (Complete 'in Triplicate) '. Application is hereby made to San'Joaquin County for a'-permit to construct.rand/or install the work herein described. This application Is made in ccnpliance with San Joaquin County-Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Cit,i :��hZ-A,=Lot Size/Acreage /eD Z2 r_ ZQ Owner's Name /:n 'I 4 C�>E? Address O 8,3-y 6 90 Phone .`* 9s E�z:�'7 Contractor ,��f��_�f $ Address License No. Phone_ TYPE OF WELL/PUMP NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ . 't PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER Q Monitoring Well ❑ i 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 f F_] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 17 Domestic/Private Ll Gravel Pack• I-] TracyType of Casing Specifications f'! Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 111} H.P. State Work Done, Well Destruction O Well Diameter Sealing Material & Depth f Depth . � Fuller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is { available within 200 feet.) i Installation will serve: Residence Commercial____ Other Number of living units: �_ Number of edrooms _ Q Character of soil to a depth of 3 feet•. Water table depth SEPTIC TANK. f„ ❑ Type/Mfg Capacity- - 2_-&a6 ,— No. Compartments PKG. TREATMENT PLT. ❑ �Y Method of Disposal Distance to nearest: Well t� =� ,�..�� Foundation Property Line /(rte �2 FT LEACHING LINE No. & Lengih of lines Notal length/size FILTER BED C) Distance to•nearest: Well 1215 Foundation 50 Property Line �_ „ 1 i SEEPAGE PITS D( Depth `Size w_ f !_ ` N,umbar ,1 SUMPS t LI Distance to nearest Well . ,�SU iFoundaiion_.�_ Property Line DISPOSAL PONDS ❑ I hereby certify that I haus 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 f Home owner or licensed agent's signature certifies the.followin k gr "I certify that in the performance of the work for which this permit is issued, I shall n t employ any person in such manner as to become subject to workman's compensaiipn laws of California," Contractor's hiring or subcontracting signature certifies the following: "I certify that in the perfoririance 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 for all required 'nspecti s. Com eta drawing on.reverse side, Signed . Title: ��u1 Date: _' 5� ' f 0 EPARTMENT USE ONLY 1 s s Application Accepted by - Date Area or Grout inspection by ate _ Final Inspection b Data / Additional Comments: s � Applicant - Return afll copies to: !San Joaquin County Public Health ,gServices,,Environmental Health Permit/Services 1601 E. Hazelton Ave., .P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE A UNT REMITTED �K RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 1321 tREV.1 N 51 �6 Els 11.26 1�r I 17D�+ �� (7GTJs -IL 6-7)