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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 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to Seo 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 L,4_40_ /� ,LoU/t 7Size/Acreage iC� Owner's Name IW�L 6110_1 Address ��3 C/a"® Tom# PPhone Contractor Q(a -IAIQf ddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Ve ❑ t. PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitaxi S ❑ DIST A EPTIC TANK. SEWER LINES. DISPOSAL FLPROP _ FOUND AGRICULTURE WELL OTHER WELLO. S/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A INSTRUCTION SPECIFICATIO D Industrial ❑OP;.-Bottom ❑ Manteca Dia. o anion - Dia..of Well Casing. ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Carlin Specifications I'1 Public D Other fl Delta Do Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump H.P. State Work Done_ Watt Destruction Sealing Material A Depth Depth Filler Material i Depth.. TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) _ Installation will serve: Residence X Commercial_ Other r.(1 Number of living units:_ Number of bedrooms ) Character of sob to a depth of 3 feet:�cs("VJ Water table depth /{ SEPTIC TANK , jl Type/Mfg FYL 5P yG Capacity No. Compartments PKG. TREATMENT PLT.❑ //� {^ Method of WI Distance to nearest: Well 1-L 0 Foundation_..rl iProperty Line LEACHING LINE No. & Length of lines / ..� g `Total length/size FILTER BED �e1' Distance to nearest: ;Well Foundation� Property Line 02 SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation 4 Property Line Q 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 lawsofCalifornia."Contractor's hiring or sub-contracting signature certifies the following: "1 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 m I Inr 11 t" d inspections. Complete drawing on reverse side. / t Signed Owe Title: Date: �U�l�- FOR DER RTMENT USE ONLY �J Application Acc)Tod by 11-01 �sPL-✓ Date ` Area yiq or Grout Inspection by Date — Final Inspection byar7%Bluer b/Date� Additional Comments: J Applicant - Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Peradt/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE PERMIT NO. _1 REV. ie31 114 a�' 1lt{.°C' t02S I M1.k2 11 91-tcow