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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 �1 RERMIT EXPIRES 1 YEAR FROM DATE ISSUED � ,6 (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 Is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City (,/,/'-�„�� Lot Size/Acreage f� Owner's Name 1'�wtL �F'I-s(.P/J� / Address>�(Q �(t7 to,l�1J��PX C.0 /1 /I,/ ' Phone 3� `p— a � Contractor JJ .l'aAddress �,9- Yl o7C 7( 7 ,.+-rfi(�_ License No.,3�Phone 64�.� 05- TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR U OTHER O Monitoring Well O 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 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing L) Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications I Public 17 Other 0 Delta Depth of Grout Seat Type of Grout I I Irrigation _ Approx. Depth I 1 Eastern Sufface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Wall Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 6 available within 200 leat.l Installation will serve: Residence Commercial_ Other AlloL=)honk e 0 Number of living units: —/— Number of Character of coil to a depth of 3 feet: b omz Water table depth 2� SEPTIC TANK V Type/Mfg LZ 141 e-4 t1LI_q_h CapaciI00 No. Compartments PKG. TREATMENT PLT. 0 r Method of Disposal Distance to nearest: Well V Ll Foundation Property Line LEACHING LINE No. & Length of lines Total length/sire 2 D FILTER BED 0 Distance to nearest: Well _ Foundation � 49z Property Line .S SEEPAGE PITS Depth Size Number 3r SUMPS LI Distance to near sr Well_16240 Foundation �f Property Line DISPOSAL PONDS U 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 .al employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I,R-�■■ 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 applican t call forI qu d inspections. Complete drawing on reverses e/) FSSigned X Title: r Date: 1 L /- FOR DEPARTMENT USE ONLY Application Accepted by �C�� Date L!i /i / (� Area J L_ L eoor Grout Inspection byDateInspection by �m�� r �ADete -�z F-(:.,Additional Comments: Applicant - Return all copies to: Sm Joaquin County Public Health L. Services, Environmental Health Permit/Services �(11 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEAMOVN7 DVE AMOUNT REMITTED CK 11 RECEIVED BY GATE PERMIT NO. NFO CASH . EN 13-24(REV ve 5) to