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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 gWiT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) Application in hereby made to San Joaquin County Tor a permit to construct and/or install the vork`herein described. This application is lade in compliance vith San Joaquin County Ordinance No. 549 at1d-1962 and the Rules and.Regulations of San Joaquin County Public Health Services. /� ^ `-.e', ' p6 l 1 rens I_� /�, AJLLb City— Lot Size/Acreage/W Job Address 7 ' Owner's Name �S Address Z,'� e T- r ' Phone �`T�� " �a Contractor lC� YAS 1 dress ��a �C 'I 'cense N0,; `� Phone I TYPE OF WELL/PUMP. NEW VALL 0 WELL'REPLACEMEN , ❑ DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION C SYSTEM REPAIR ❑ t OTHER O Monitoring Well 0 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 L.1 Industrial Cl Open Bottom_ 0 Manteca Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I'I Public 1-.1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation ..._1:Appro-. Depth I I Eastern Surface Seal Installed by 1111 Repair Work Done 0 Type of Pump H.P. _, [ -- State Work Done_ Well Destruction 0 Wall Diameter' Sealing Material A Depth Depth I - Piller Material &'Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION II (No septic system permitted if public so"? Is available within 200 fast.I Installation will servo: Residence •Commercial Other ;: ;,-• -- Number o1 kving units: _ Number of bedrooms `• Character of snit to a depth of 3 feet! Cs x7r�6e Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments _ „t PKG. TREATMENT PLT. 0 j ,tl r`r' �f Method of Disposal ' Dlstanoa to nearest: Well 1! Foundation Property Line ' LEACHING LINE LT No. b Length of lines " "' Total length/ske FILTER BED) 0 Distance to nearest: Well Foundation Property Line C, SEEPAGE PITS r I Depth�.. ! Sire 1 I 1 Number SUMPS - LI :Distenoa to nearest; Well ! L Foundation Property Line DISPOSAL PONDS 0 V "J 1 I hereby oartlty,that I have prepared this application and that iii.work.wili.bedond in accordance with San Joaquin county ordinances, state laws, and miss and regulationi-of-tha'Sdn J6aQ01n'0ounty" , 1. ' 1 1 1 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 parson in such manner as to become subject to workman's coAtpensation lam of California." Contractor's hiring of sub-contracting signature cenHiss the following:"I CORKY that In the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion Is"of California."t 1 � i 1 The applicant must call for all re Ir specie s. Complete drawing on reverse side. 1 1 SWn Title: Date: /.-`., �, , 1 FOR-DEPAR MENT USE ONLY Application Accepted t , _ Date Area Pit or Grout Inspection by Date Final Inspection by � Data Z Zy 9a Additions!Comments: Tr✓S� lo /�-S�G7 ✓t�iY7f 4��- 7�LS�fa, �a9'e� •fx6lf (-076 Applicant - Return all copies ton San Joaquin Caunty Public Health Services, Environmental Health Permit/Services ` _ )1601 E. Hazelton Ave., P 0 Roz 2009. Stockton, CA 95201 INFE AMOUNT DUE AMOUNT REMITTED CASH If RECEIVED BY DAtT�E PERMIT NO. . Ea 11.24 IAtV.t/esi O, V S p-.�O -90 o —/by 11 n4a