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APPLICATION FOR PERMIT J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1ENVIRONMENTAL HEALTH DIVISION 601 E . HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DA E ED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ! . 5k9 and 1862 and the Rules and Regulations application is made in compliance vith San Joaquin County Ordinance Noof San f Joaquin County Public Health Services. E 3 � Job Address yJ -7"RA C' �Rfge� I � 6L VD ' City Lot Size/Acreage ' A A Owner's Name M I L 01 o P• Address r Phone 6V19 9$3-2620 t Contractor 7 !1 Address 3 3 C.B t �� `°�°A' License No. 3 �r9T�Phon b'38*7276 TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ i SYSTEM REPAIR 0 OTHER C) Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWEii LINES DISPOSAL FLD. PROP. ROP. LINE C w - FOUNDATION. .AGRICULTURE WELL - .OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEMAREA TCONSTFiUCTION SPECIFICATIOrt n Industrial ❑ Open Bottom ❑ Manteca Domestic/Private Dia. of 1+Ve11 Excavation ! , y4 -- Dia• of Well Casing J9Gravel Pack PQ Tracy Type of Casing f YC i'1 Public fa Other a fl Delta i ! Specifications Depth of;•Grout Seal _ Type of Grout N ! I Irri{lation Approx. Depth I I Eastern Surface Seal Installed by cS ^` Repair Work Done ❑ Type of Pump I H P E J State Work Done Well Destruction ❑ Wel! Diameter Sealing Material rE Depth `fV Depth Filler Material & Depth _ 4 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlALMIION f 1 DESTRUCTION I I Wo septic -jr system permitted if public sewer is Installation will serve: available within 200 feet.) Residence `Commercial Other Number of living units: Number of bedrooms # ' t Character of soil to a depth of 3 feet: [ �� T SEPTIC TANK - i Water table depth Type/Mfg PKG. TREATMENT PLT. ❑ Capacity No.,Compartments f Method of Disposal Distance to nearest: Well ` Foundatio Property Line x� r LEACHING LINE Cl No. & Length of lines} 1 Total length/size L FILTER BED ❑ Distance to nearest: Well Foundationk• Property Line SEEPAGE PITS It Depth Size t SUMPS Number (� r , ^� yam... s f l Distance to nearest: Well Foundation L Property Line "�DISP05A'L PONDS"��p�..��w�...�,..:- ;...,�„_,,._. `^� � �--: _ .... .�•-. __ ' F : 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 rules and regulations of the San Joaquin County r Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not I employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subAbt to workman's compensa- tion laws of California." The applicant must call for all required inspe ns. Complete drawing on reverse side. Signed X /-.�p� �— Title: ��2c�T rr � 040�1Si- Date: Z3 J0 FOR DEPARTMENT USE ONLY 1 Application Accepted by r LI Date A ,,. Area / 1 Pit or Grout Inspection by.r t_pDate c Final Inspection by C� oatt Additional Comments: f/ [�.�• ��Fublic Applicant - Return all copies to: San Joaquin Counta h Services, Environmental Health Permit/Services ;: 1601 E. Hazelton Ave., P 0 x 200ZStockton, 95201 FEE AMOUNT DUE MOUNT REMITTEDNFO __ .�7CASH DATE PERMIT'NO. EH 13-24 tREV.r�nsi ]S�/ 7 � EH 4446 [J 7