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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �l ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 a � j ✓ RERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Seat 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. ,,1 Job Address ' VU1 5. �At-MN"] Y A- City Lot Size/Acreage 10 Arvr_ Owner's Name At�D� f�/1T.it- yC3 i()1,� *1 1100 UiS iC R 0AD rA VM2M CA 1 Z�c�j�5rj _ ,5r1 Address Phone Contractor ow'myN Address t t30 �Aslic_Af p� License No. � Phone tfW7 } ' TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT [D DESTRUCTION 0 Out of Service We1I ❑ PUMP INSTALLATION SYSTEM REP OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK it� EWER LINES DISPOSAL FLD. � PROP. LINEIoc"V`r' f FOUNDATION AG I ULTU ELL1O00 r OTHER WELL C PITS/SUMPS I 1 INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS 0 Industrial Propen Bottom �aE `M nfeca� ` a. of Well Excavation Dia. of Well Casing2lhDAIK- ipomestic/Private ❑ Gravel Pack i L7 Tracy Typ \of Casing p;ASTa� {71 Specifications ` FI Public f:7 Other it Delta Depth of Grout Seal Type of Groutctie-pm I # Irrigation _,Approx. Depth t I Eastern Surface Seal1Ttstalled by f 114MRepair Work Done r Type of Pum�t�� LA- ZA H.P. 3 State-Wo. Done FWell Destruction Q-'_Well Diameter 1l�t�CE.d Sealing Material 6 Depth Depth tr u` Filler Material & Depth t TYPE OF SEPTIC WORK: NEW INSTAL ` TION REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence 'L Commercial Other Number of living units: Number of bedrooms t Q Character of soil to a depth of 3 feet: '�'�'"t''"' Water table depth ( SEPTIC TANK ❑ Type/Mfg `�A Capacity.lk*- No. Compartments F_ PKG. TREATMENT PET. ❑ Method[qt Disposal Distance to nearest: Well Foundation Property Line t0 } U �} ►_ LEACHING LINE _� & Length of lines _ '^ otal length/si2e_:+ � FILTER BED �7 Distance to �tearest: Well! Foundatior._ 0 Property Line w p tfSEEPAGE PETS Size d - Dumber I C G s SUMPS Distance 1c ne,Jrest: Well Foundation -- Property Line !I C DISPOSAL PONDS L f I hereby cenify that I have prepared this application and that the work wiil be done in accordance with San Joaquin county ordinances, state laws, and`` j 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 shafl employ persons subject to workman's compensa- tion laws of California." The applicant mu .call for all required," spections. Complete drawing on re side. Signed Title: S " F. R DEPARTMENT USE ONLY Application Accepted by Q� Date 7X (Z) it r Grout Inspection by Date Final inspection by Date Additional Comments: Alkl( ) Y t� �1 Applic t - Returp all co 6 tpti San Joaquin County Public Health ? # } ry Services, Environmental Eealth Permit/ServicesCdrz + If' x.601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 'sf ft`iCY � � II I q�j t♦ f0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE PERMIT'NO. E _H 13-N{REV. 4;EH14-26 1.• l�L �� C, Cs' �jr�