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APPLICATION FOR PERMIT 74 SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--320 P O BOX 2009, STOCKTON, CA 95201 EXP RTsS�1 YEAR FROM DATE ED (Complete in Triplicate pplication is hereby trade to Sant Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with Ban Jo in County o finance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �S �—=E- _ 19 2. r City � f� _ Lot Size/Acreage ` J I it Job Address II JI�l�F ri�u l %�"t"Phone L I Owner's Name ��` ��— �ddress ��7 dl - 2�yr�,�! �+ License No.�Q.,,2iLCLL Phone Contractor b Address WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ Ij TYPE OF WELL/PUMP: v. NEW WELL ❑ if -��1 it o i Well PUMP INSTALLATION ❑ SYSTEM REPAIR # l ❑�� I? DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PR P. L �Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "l SPECIFICATIONS, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONDia. of Well Casing }•�– 2/ II L7 Industrial ❑ Open Bottom '❑ Manteca Dia. of Well Excavation Ij Type of Casing�t� Specifications --- Cl Domestic ❑ Gravel Pack. L7� �Tracy Type of Grout i! 1'I Public (-I Other rw-6.ita Depth of Grout Seal 1+ I i Irrigation -._._..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. $ to o Done I� Sealing Material & Depth J Well Destruction Well DiameterC Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION 1 1 DESTRUCTION ( I-(Noavaseptic hitt system matted if public sewer is f . a{ installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms I� Water table depth Character of soil to a depth of 3 feet: 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments – ll' Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property.Line ii I LEACHING LINE LI No. & Length of lines Total length/size II; CI Distance to nearest: Well Foundation Property Line FILTER BED i� Ir SEEPAGE PITS 11 Depth Size Number 4 gUfµpgLI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS --❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and u rules and regulations of the San Joaquin County I+ llowing: "I certify that in the periormance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the to 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 must 7call Qfor raall req r ins ctions. Complete drawing on reverse side. Signed X ��/i Tri r R _ Title: � ' Date: I � FO IDE RTMENT USE ONLY Application Accepted by Date Area Pit Grout I spection by Date 30 Final Inspection by Data Additional Comments: ` Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P x 2909, Stockton, CA 95201 at!;E AMOUNT REMITTED CK RECEIVED BY DATE- PERMI 'NO. EH 17-24(REV.1/115)EH 14-26