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APPLICATION 'FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , �PHONE (209)46$-3420 I IP O BOX 2009, STOCKTON, CA 95201 t+� PER}��T EMPIRES 1 YEAR FROM DATE ISSUED (Complete in triplicate) ��J, Appllcat on is hereby de,to Joaquin County for a permit to construct and/or install the Work herein described. This application is made in compliance with San Joaquin County Ordlnance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. �j L4Jc-ST S1 Job Address � � (7� 9 '! City Lot Size/Acreage Owners Name Luo r F tn,(Zm{!�(q Address ZQ2 /1/c L�L/t/L� $(IL/1� Phone 1 cfg ^ V 2 Contractor C0 Address (4-A-00 L L—i�-V License Ner�r-'�J �J Phone rJ � 1 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEMI REPAIR ❑ OTHER ❑ Monitoring Well �7 I _DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1M DISPOSAL FLD. PROP. LINE y� FOUNDATION AGRICULTURE WELD. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� C.7 Industrial ❑ Open Bottom n Manteca Dia. of Weil Excavation.__� Dia. of Well Casing `r�r (� Domestic/Private D Gravel Pack ❑ Trac T I ' Tracy Type of Easing Specifications I'? Public CI Other 1-1 Delta Depth ofy0'rout Seal Type of Grout 11 Irrigation T Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done Type of Pump 5 H.P. T ( State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Y l �✓ S 4,✓� DepthFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION c I REPAIR/ADDITION I iDESTRUCTION I 1 INo septic system permitted it public sewer is k available within 200 feet.) ) Installation will serve: 'Residence— Commercial_ Other.Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r Water sable depth 111 SEPTIC TANK O Type/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT, 13r Method of Disposal L'1 I p Distance to nearest: Well Foundation Property rine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED D Distance to nearest: Weil Foundation Property Line fA- �- SEEPAGE PITS 11 Depth Size _ Number SUMPS Lt Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Q. f 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 theSanJoaquin county Home owner or licensed agent's signature certifies the following: I certify that in�the g 9 g: ' Y performance of the work for which this permit is issued, I shell nos employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature p certifies the following: "1 certify that in the performance of the work for which this hermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." q` l The applicant mus !for all to uired inspections. C piece drawing on r rse Signed X �~ Title: } Date: I 'FOR DEPARTMENT USE ONLY Application Accepted by Date 7 1S Area 2-1 2 A Pit or Grout inspection by Data ✓ Final Inspection by -. „ � Date 2 Additional Comments: n Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 I; FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERM!7'NO. EH17 .24.20 5 EM EV.kip �� s) l 0 '•fes ` 1 r