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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON , CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made tc San Joaquin County for a permit to construct and/or install the work herein described. Tnis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County /Puublit Health Services. 14110/V 1. Job Address yG'C� A! ��. �S c.� x/1/4✓ City .S7`'>rr,�.�y-on Lot Size/Acreage % "/7 -U 4' Owner's Name Sr4n Zev mocre Address �-?S L thar7'Y-/ _ Phone Contracto r 111dWe., Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION a Out of Service Wel; ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER C Monitoring Wel! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom a Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1_1 Other M Delta Depth of Grout Seal Type of Grout I i Irrigation —Approx. Depth 1 1 Eastern Surface Seal Installed by Repair Work Done U 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 REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: riA e Sa . T Y;1} Water table depth / SEPTIC TANK Q Type/Mfg /�}�' L Capacity 0 No. Compartments 000l PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �3010 Foundation 7_ Property Line LEACHING LINE t3! No. 8 Length of lines x f Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line ^%b SEEPAGE PITS 1:1r Depth / ,S Size _�fj' Number SUMPS LI Distance to nearest: Well ? Qe, Foundation 'VG " Property Line .S 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: "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."�yy The applicant m ca .tbr all required inspections. Complete drawing on reverse side. Signed X Title: (I w,-) r r Date: FOR DEPARTMENT USE ONLY Application Accepted by Date q1 Area r--,< /7— Pit or Grout Inspection by Pale Final Inspection by Date Additional Comments: � � i Applicant - Return all copies to: San Joaquin County Publ c Health Services, Environnental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REEMITTED CK CASH_ R ECEI �/V 1E �D BY DATE PERM17 N01 • EH 13-24(REV.iin5i 1 .�� 1 I (JV 12�-1,2 1�1\ �. I I 1� EH i3-2e 1 l