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APPLICATION FOR PERMIT oaf SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 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 Serviicceess..� r r� > yJI Job Address 1,40��0 f h.Lf n�r- DE I5�1 City cl f _tit Lot Size/Acreage © - Owner's Name 1 !1\ 11"' �D`.�'t �E`�/ Address `?© ��--�� k�MM+5Phone 3,6q 137 p Contractor Address �0�E7 / .mow+rI �5� '--0_SS/`t-Phone TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well O - -- --RUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK �'7L SEWER LINES �� DISPOSAL FLO.10rt 1 � PROP. LINE _1V1 FOUNDATION 0' AGRICULTURE WELL OTHER WELL - PITS/SUMPS LTD -r- INTENDED INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p VA, ❑ Industrial X5pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `Koomestic/Private ❑ Gravel Pack O Tracy Type of Casing 5J-4sx-Q Specifications . 15-4 11 Public 1-1 Other ❑ Delta Depth of Grout Seal sC Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed b Repair Work Done O Type of Pum H.P. Work Done _ Well Destruction O Well Di ter Sealing Material i D Dept Filler Materi Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is ti available within 200 feet) Installation will serve: Residence— Commercial_ Other Number of living units: _ Number of bedrooms C Character of soil to a depth of 3 feel Water table depth SEPTIC TANK ❑ Type/Mfg - .__. Capacity No. Compartments. / PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to near Well Foundation - Property Line _ LEACHING LINE ❑ No. g Le th of lines Total length/size FILTER BED Cl Dista a to nearest: Well Foundation Property Line SEEPAGE PITS 11 epth Size Number SUMPS 1 LI Distance to nearest: Well Foundation Property Line _r DISPOSAL PONDS I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county tdinances, state laws, and k 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 thisrmit 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 of sub-contracting signature certifies the following: "I certify that in the performance of th8'Work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California The applicant mus reit quire inspeeLt� Complet0 drawing on reverse side T� Signed X I ei `�fiL/+4rd� Date: f�Qd _ R DEPARTMENT USE ONLY ADZlionpted by Dace l/ `V �+/J�V� r�Area I �- Pit Grou Inspection by - Date Lr� QFinal Inspection by Date6% Additional Comments: 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 EE INFO AAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT/^NO. . EH 13-211REV,11x51 !�_�U.ZO C` tj '�X7