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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � r ev ENVIROENTAL HEALTA DIVISION 1.601 E HAZELNT N AVE. , PHONE (209)468-3420 gP �•!f►r P O BOX 2009, STOCKTON, CA 95201 A SqN R �j U / PEuuTT EXPIRES 1 YEAR FROM DATE ISaNED EN�/'�ON � (Complete in Triplicate) ii, Application 18 hereby made to San Joaquin County for a permit to construct and/or install the vork herein describ�drysS+ application is made in co4liance with San Joaquin County Ordinance Noi 51+9 and 1862 and the Rules and Regulations 0f�jr Joaquin County Public H(e�,alth Sed�u Job Address �'' "^ w r`rt� S� [C1y�er� City ^" Lot Size/Acreage GLCv-e S t (40-0 Owner's Name 5� ` flddress 1 30 <1• Vi _X-+ �— Phone 'T33- 1 C46 6 �a T Z�25 e, tM��fi CS-7 (F-6eD Contractor S+ �`^ ^� Address r- u^ JAZ 1 License fro,s M 7-2-62r.Phone 9 65- "67 1 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE11RUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 5 5`; �E'�THER Monitoring Well ❑ Hor.r,q5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL S PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Gl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I1 Domestic/Private ❑ Gravel Pal ❑ Tracy Type of Casing I Specifications ~ ("I Public �fsZ Other sem°�t%n9 F1 Delta Depth of Grout Seal Type of Grout CA I I Irrigation 1�.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. IState Work Done Weil Destruction - ❑ mater C Sealing Material & Depth +a Depth Z -C h G Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will-serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacit). No. Compartments PKG. TREATMENT PLT. ❑ Method 0f Disposal J Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cenifies 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 compensa- tion laws of California." The applist call or all quire inspections. Complete drawing on reverse side. Signed XZ Title: S'ey�O Date: 4 3 R D P MENT USE ONLY Application Accepted by C Date4'3 Area y q - �j Pit or Grout Inspection by `` - Dg r Final Inst ection by ! 1C- Date� / + r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Pertait/Services 1601 E. Hazelton Ave., P 0 Box 2009 Stockton, CA 95201 1 FEE AMOUNT DUE -AMOUNT REMITTED CK r RECEIVED BY DATE PERMIT'NO, INFO M CASH EH 13.24IREV.+�h5) zs-isb EH iI-�