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v APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES[.3 E'��o/ ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r6/-C , (Complete in Triplicate) Application 1s hereby made to San 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. //� 1d6^^�_ � � -- p Job Address -27� / `-tet City / Lot Size/Acreage �/L G -� tton _ /01 / /r Phone 3 Owner's Name r_l ,TLQ t/.1' Address U�Sb(n �� ,^r p �q //pp Contractor "Idress�O- Y3 -A- 7(7 Gest License No.32,F zd_Phone a --5 of 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 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 Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth y Depth Filler Material i Depth J`J TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is 6 r available within 200 feet.) Installation will serve: Residence X_ Commercial_ Other 12 i !z ONt e 0 Number of living units: --IL Number of b f oms 126 Character of soil to a desp7Ith of 3 feet: _ Water table depth SEPTIC TANK F Type/Mfg F✓' KGsf, C_a_na_c_itya 00 No, Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation AQ Property Line-S 7 LEACHING LINE No. i Length of lines — 410 Total length/size 2 0 FILTER BED Cl Distance to nearest: Well Foundation � � r Properly Line SEEPAGE PITS Depth Size ��,� � Number SUMPS LI Distance to neer t: Well Foundation 1,0 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 canities 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." Contractors 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 Ism of California." The applican t call I qu for d inspections. Complete drawing on reverse s / /J t Signed Title: Date: FOR DEPARTMENT USE ONLY �/ �/ Application Accepted by Date c-4-2 /i / �D Area3--- y �a/! �or Grout Inspection by Date �Finel Inspection by �,E;�L .pDats ZZ C✓ Additional Comments: ��__ Applicant - Return all copies to: San Joaquin County Public Health irvry(� Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EH 17-24 MEV.11.mi EH A-211 1 �• 0 G 30 -1 0�