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APPLICATION FOR PERMIT A + t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON;;AVE. , PHONE (209)46873420 PAYMENT ..P 0 BOX 2009, STOCKTON, CA 95201_ PFMXIJ EMIRES 1J. YEAR FROM .DATE ISSUM MAY 2 0 (Complete in Triplicate) YY q 1N COUNTY c>•i�' �i This Application is hereby made to San Joaquin County fora permit to construct and/or install theS rhe . application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the � �¢�tlat gr�`;pf;San Joequin County Public Health SServices.y�� ,( kIJVlRONM 4 Job Address `�5 ' ncr - 'e City. Lot Size/Acreage t+lPi ,B�f 4f5 _ ' Phone �� �5 Owner's Name � Address � 3$SS nl:gKs�n��G�r.�rLi. boz/„� 95°m Contractor. --raw-_--raw-_ Address ' cense.No. �Phone TYPE OF WELL/PUMP: NEW WELL C3E: WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ Monitoring Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR D SQA/i�O ` THER 9 A. 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 3/" q �� PLt5W 2Z' �� 0 Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4 Specifications I'l Public i 1 Other fl Delta Depth of Grout Seal Type of Grout A&(,� I I Irrivatton —.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Weil Diameter Sealing Material &"Depth Depth Fi11er.Materia.1 & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial.-.r Other - Number of living units: Number of bedrooms l Character of soil to a depth.of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg " Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines -Total length/size FILTER BED 0 Distance to nearest: Weil Foundation Property Line. SEEPAGE PITS 1.1 Depth Size Number SUMPS Ll Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ `_ I hereby certify that I have prepared this application and that th'a 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, l 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- E tion laws of Caiiforni The applicant mus for all required ins coons. Complete drawing on reverse side. .�,•,�/"-' c�.p Signed Title:' `��'lug` _ Data: 4 FORlDEPARTMENT.USE ONLY Application Accepted by !` Date Area 4AI-r? Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: E. 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 K 11 INFO AMOUNT DUE AMOUNT REMITTED CASH RE E ED BY D�ATE.f / PERMIT'NO. EN 13-24IREV.;/K5; 5,I .g ' �� 15 312 d •v+ !r glf!(l>� EN:1-25