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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH S RVICES ENVIRONMENTAL HEALTH DIVISION ` »n 1601 E. HAZELTON AVE. , PHONE (209)468-3420L ��illll ■l P 0 BOR 2009, STOCKTON, CA 95201 RXMIT 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 Se 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 3 9-?-9 AIU.Cj%fl/' D AUS City SYK.✓ Lot Size/Acreage 1*9X 420 Owner's Name SID RaNA D6n/n/A Address S/47" - Phone 3 - Contractor FcOYD 4, Q/Oon Address Al, AAF +tea r A-!/E License No. S�7-:r-276 Phone 4&S"-8 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RICULTURE W OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A A C STRUCTION SPECIFICATIONS (1 Industrial ❑ DPen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public 1-1 Other f1 Delta th of Grout Seal Type of Grout I I Irrigation _.Apprux, Depth 1 I E ern Su a Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Materi L Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION Nnse_ tu, s��r�� fitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other LOT of 6X IS T/tiIG 13 Number of living units: —L Number of bedrooms 2- Pie/pr(' 7-V 19 7.2 Character of soil to a depth of 3 feet: CLAY a pt SEPTIC TANK 09'Type/Mfg CO- Pd L Capacity aOOO No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -7 Foundation fQ' Property Line 40' LEACHING LINE No. 8 Length of lines 3 -/,01 Total length/size 160 ' FILTER SED ❑ Distance to nearest: Well Foundation /fJr?' Properly Line 40 ,5 i SEEPAGE PITS for De th 2C� r� 0 Sire Number .3 (� SUMPS LI Distance to nearest: Well 1Z Foundation 7A0 Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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, 1 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 applicant must call for all required inspections, Complete drawing on reverse side. Signed X �� a4,-es, Title: &IaL- Date: 7-/A-90 /1!(��11- �AI� EPARTMENT USE ONLY f, q Application Accepted by '""ate t,- Date �- T� `� Are Pit or Grout Inspection by Date Final Inspection by 7 / Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services N~ 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED ASH /1 RECEIVED BY DATE PERMIT NO, . EH 11-24(REV.".5J '1 �� -A11(2A EH;6211 l r/