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APPLICATION FOR PERMIT SAN OAQUIN COUNTY PUBLIC HEALTH SERVICES � Q W ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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 ..,[r SAO 1-0 W E R— SA e--AA MF/� PtD City S77eq/ Lot Size/Acreage �AG.,C6S Owner's Name VAj. CAe/ ASSOG.iATLe8 Address PO 6nh 99A .5 ,✓ Phone Contractor FLOYD G, LtJOol7 Address 7 A),Ap",6 ;- AJ✓E License No. YS3.71 Phone s 397/ 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 FLO. 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout — I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 21)0 fest.) b Installation will serve: Residence_ Commercial'/Other REVhSED d�IL<,1/ASG, Number of living units: _ Number of bedrooms (� Ic;J Character of soil to a depth of 3 feet: C L A 9' Water table depth SEPTIC TANK ❑ Type/Mfg 0#--L- Capacity /60A No. Compartments 2- PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well / f Foundation 7 Property Line 20 r LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS )I Depth )-Sr Size �r+0� Number 7- SUMPS LI Distance to nearest: Well 1 C0 l" Foundation 301 Property Line �r 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 laws of California." 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 must call for Dall required inspections. Complete drawing on mover"side. Signed K c�L�W �t/?�m- Title: CtrLf[. Date: ��FOR DEPARTMENT USE ONLY Application Accepted by - Date Area IPit or Grout Inspection by /. Date Final Inspection by _ Date Additional Comments: �e �f -0-Ae Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 1 RECEIVED By DATE PERMITNO. INFO CASH `3 � . EH 1324MWE Irx5i z/[/ / V -3/V EH it N 7