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N w APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-5420 P 0 BOX 2009, STOCKTON, CA 95201 REMIT 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �6 05 'Tr� A aU p E City - Lot Size/Acreage i Owner's Name 0L _)E m Z LD C,,k__ Address Phone Contractor Ml�i LA hLf"_ G& �llddress s3S� �� C��ense No.-43ow Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C] +DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .: Y. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications j i'l Public is Other n Delta Depth of Grout Seal Type of Grout I I Irrivation _.Approx. Depth l I Eastern Surface"Seal installed by .f1, Repair Work Done U Type of Pump -H.P:- '" !- State Work Done Welt Destruction ❑ Well Diameter Sealing Material-&-Depth Depth " "Filler""Material & Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION TRUCTION I l INo septic system permitted if public sewer is 0 available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: _ r Number of bedrooms y "f Character of soli to a depth of 3 lest: C- i �! �. ;� - _..... Water labia depth SEPTIC TANK. ! ❑ Type/Mfg Capacity No. Compartments 1 PKG.TREATMENT PLT. ❑ Method of Disposal J ! Distance to nearest: Well Foundation Property Line LEACHING LINE L-_N_o-A Length of lines _ �-{�'� Notal length/size FILTER BED ❑ Distance to nearest: Well foundation74 Property Line SEEPAGE PITS 04--oapth Size Num-or SUMPS L1 Distance to nearest: Well Foundation� Property Line 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 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 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 subject to workman's compenss- tio s of California." The applica u t ca i r all qui in ct ns. mplate drawing on reverse sid Signed Title: f Date: " Tu S F DEPARTMENT USE ONLY a, Application Accepted by Cna 44 1,, Date 6� Area Pit or Grout Inspection by Date Final Inspecti-on by Date Additional Comments- Applicant - Return all copies to: San Joaquin County Public Health - Serv"ices;-Environmental-:Health-Permit/Services 1601.E. "Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 AMOUNT INFO MOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. + EH13„21 TREY.11 n 5f EH 41.26