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APPLICATION FOR PERMIT k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ` f Job Address o2�0�5 7-,e,¢ jnj/¢ [�f City L Lot Size/Acreage Owner's Name tt� N Address Phone i Contracfoi �� L`ZIG� "I� _._.Address >i�/T LicenseiYo� js� Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT. F1DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER El Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK,f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing - , ['.]'Domestic/Private ❑ Gravel+Pa{ck 0 Tracy Type of Casing Specifications l F1 Public t-1 Other ❑ Delta Depth of Grout Seal Type of Grout r I Irrigation _.Approx. Depth I I Eastern Surface Sedi Installed by Repair Work Done U Type of-Pump 3 H.P. State Work Done ° �] Well Destruction ❑ Well Diameter Sealing Material & Depth Depth i Filler Material & Depth TYPE OF SEPTIC WORK: NEW:INSTALLATION REPAIR/ADDITION I E DESTRUCTION ISI [No septic system permitted if public sewer is 1t available within 200 feet.) Installation will serve: Residence L� Commercial Other Number of living units: r Number of bedroa _ Character of soil to a depth,of 3 feet: Water table depth SEPTIC TANK. ❑.( !Type/Mfg E2,4 L . Capacity No. Compartments i PKG. TREATMENT PLT. 6 ' ��7" r7— Method of Disposal i Distance to nearest: Will. ffV _ Foundation _ Property Line LEACHING LINE f/ No. & Length of lines F 7- Total length/size 6 �T FILTER BED i ❑ Distance to nearest: Wei FILTER Foundation Property Line • f i / 07 SEEPAGE PITS 4 {r % l 1 Depth 4(5�f Size Number SUMPS ,Distance to nearest: Well Foundation / �� Property Lines fT DISPOSAL PONDS! :- D ' I hereby certify.6at f 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____�_ 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 person,in such manner as to become subject to w.orkman'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 subject to workman's compensa- tion laws of California." The applicant must call for all quired spections. Complete drawing on reverse side. Signed °f r Title: Date: QH DEPARTMENT USE ONLY � a 4 Application Accepted by Date `� Area '" Pit or Grout/Inspection by Date Final Inspection by Date 3 9 Additional Comments: Applicatit — Return all copies to: Ben Joaquin County Public Health Servicea, Environmental Health Permit/Services w- ' 1603 E. Hazelton-Ave.., P 0 Box 20095 "Stockton, CA 95201 L ! INFO OUNT DtJfi AMOUNT R�EMrITTED CASH RECEIVED BY DATE PERMIT NO, a EH 13-1411tEV.r/a51 /� (� ��f' (�'�G i `'b EH 14-2e V