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APPLICATION ]FOR PERMIT SAN 'JOAQUIN COUNTY PUBLIC HEALTH SERVICESPic ENVIRONMENTAL HEALTH DIVISION 1601 E, HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA. 95201 PERNII EXPIRES 1 YEAR FROM DATE TD (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 1662 and the Rules and Regulations of San Joaquin Country t ��_W Public health Services.71t� ,,( Job Address -5 .0 -+ ►`"ter City IE Lot Size/Acreage 10 CLC. Owner's Name SO\°`., Address �1t�� '� � �'� � Phone Co&'�k Contractor—& Sk_-- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR-rt OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Welt Casing E) Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ('1 Public (D Other f1 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_ p� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 8 Depth Q TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence–Y, Commercial_. Oilier Number of living units: —L Number of bedrooms " Character of soil to a depth of 3 feet:.. L d'kVA Water table depth SEPTIC TANK I5. Type/Mf �,_ 4+�1i��f `' , g;-�-�f Capacity � No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ki-A, )k t Distance to nearest: Well ` Foundation JG Property Line r LEACHING LINE $4 No. & Length of lines Total length/size FILTER BED C7 Distance.to nearest: Well Foundation �� _ Property Line _Z SEEPAGE PITS K Depth Size 12 Number SUMPS Ll Distance to nearest: Well 0, Foundation Property Line 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, an 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: "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 applicant m t tali for all required inspections. Complete drawing on reverse side. r. 1 Signed Title: — _ _ _ Date: 9 -.9 0 ....._ i F, DEPARTMENT USE ONLY } Application Accepted byQ Date Area Grout Inspection by - Date �� Final Inspection by Date�� Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hat:elton Ave., F 0 Box 2909, Stockton, CA 95201 FEE INFO AMOUK,,DUE AMO" EMITTED CASH RECEIVED BY DATE PERMIT"NO. a + EH '241AEV,r�nsl '4 �` Qt,f_Cja� EH;4.28 -j 0 f ��