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APPLICATION FOR PERMIT 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 E7PIRES T YEAR FROM DATE ISSUED ' (Complete JA Triplicate) Application is hereby made to San Joaquin County for a Permit to construct and/or Install the work herein described. This application in made in eo�liance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Serad ices.. x7 A ' Job Address / " E13�C7! /.d City Lot size/Acreage Owner's Name � �-A p �^s/ �lsrtSr� Phone ' Contractor 74M ddress icense No/ 240 hone TYPE OF WE LIP MP: NEW ELL ❑ WELL REPLACEMENT DESTRUCTION 0 Out of service Reil ❑ PUMP INSTALLATION-❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Cl Domesticl Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications Il Public ❑ Other fl Delta Depth of Grout Seal Type of Grout ' I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done- ,) Well Destruction ❑ Well Diameter Sealing Material & th !' Depth Piller Material h ' TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION i DESTRUCTION I I iNo septic system permitted if public sawer is oQ available within 200 icet.l Installation will serve: Residence_ Commercial_ Other Number of living units: — Number of bedrooms ' Character of seg to a depth of 3 lett: Water tabla depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ' Distance to nearest: Well _- Foundation Property Line a LEACHING LINE Cl No. 6 Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well_ Foundation 46�2— Property Line,_/_G-?g 7z EPAGE P 11. Depth Size v Number J ' � SS PS 0 Distance to nearest: Well 1P1 Foundation-J? 6 Property Line R 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, stale taws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature canities the following: "I contly-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 workmen's compensation laws of California." Conlractor's hiring or subcontracting signature ' candies the following:"I certify that in the performanca of the work for which this permit is issued,i shall employ persons subject to workman's compensa� tion laws of California." The applicant st f I quire s actions. Complel drawing on roveragFlde. Signed Title: l,D`G"'�•,�)a, ✓k Dater ' ORD P V.SE ONLY Application Accepted by Dais Area ' Pit or Grout Inspection by Date Final Inspection by - )rf SSDY`-. Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ' Services, Eoviroomental Health Permit/services 1601 S. Haaelton Ave., P 0 Box 2009, St"Icton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. NFO / ❑ p ' sERt3-24IREV.t/x5I x"7orb� ,F•o f .+✓f 10 o—dZ1..g3 EN i41e Y