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M APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 pF aKIT EXPIRES 1 YEAR FROM RATE ISSUB—D (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. �//� 7iJ� jry�� 6City dam. Lot Size/Acreage .lob Address ._.., J �� -eX ress Phone Owner's Name - . - � �r-11 Contractor Address .S c9- icense No. ` � Ihone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_)' DESTRUCTION ❑ Out of Service Weil L] PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK_J' SEWER LINES `-DISP SAL FLD, "PROP-L-FNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYP9 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public C] Oth i n Delta Depth of Grout Seal Type of Grout ` I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by � Repair Work Done 0 Type of Pump 1�jl . H . �`_ State Work Dome ')Sealing Material & Depth Well Destruction ❑ Well Di meter ,, t.,,-„ Depth I Filer_Material & Depth TYPE OF SEPTIC WORK: NEWiNSTALLATiON REPAIRJADbITION 111h RFySTfiLICTION I I {No septic system permitted iT public sewer is S available within 200 feet.) 'Installation will serve: Residence� Commercial_ Other i �- E Number of liviriunits:� �� - t Number of bedroom s�_� r -Df Character of soil to a depth of 3 feet: r� j 64 Water table depth € SEPTIC TANK ❑ Type/Mfg ICapac ty • �No. Compartments 157— PKG. TREATMENT PLT. D � { Method of Disposal a t ` � Distance to nearest: well ��D Foundation Property Line �� t ------� i LEACHING LINE ,d 011 No, & Length of lines � Total length/size FILTER BED ❑� Distance to nearest: Well " ,�'"4F . oUttndationAProperty Line / SEEPAGE PITS l 11 Depth size -� _ Number SUMPS CI Distance to nearest: Wall �S� Foundation, 1�� Property Line DISPOSAL PONDS ❑ I hereby cartifiy than have plepared this application a4d that the work will be done in accordance with San Joaquin county 6%inances, state laws, and rules and regulations'of the �an Joaquin County ) Home owner or licensed agent's signature certifies the;following: "I certify that in the performance cif the work for which this permit is issued f 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-p the work for w ' h_this-permit-is.issued, I shall employ persons subject to workman's I ompensa- tion laws of Califoin1. `: f The applicant must call for all required insPections. Complete drawing on reverse side. Signed ?(�_ f's.t' _ T�tie:_.,... arG�-�•�•• _ Date: 7 c� PARTMENT USE ONLY a�a �•,� �..,. OR-DE Application Act epted,by Date Area i Pit or Grout lnipection by Date Final Lnspection by Date 40 i 1 1 Additional Comments; t ` { Applicant - Return all oipies to: San Joaq n C6unty Pub is Health w Services, Environmen Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 !FEE AMO NT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO . EH 19.24 IREV.v h 5S EH 14.2E 10 l