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_ _sy APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PF,RMII EXPLRES YEAR FROMDATE (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. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address SW: W. 155 I Al+r Ii'a A D City�SL Lot Size/Acreage Owner's Name $h/1 _ ddress • Phone THru�'L OCL ?Jhr%M i cavAl � /''4 /' �� /7v Contractor 4� Address Z' License No��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION XOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack C Tracy Type of Casing Specifications I'1 Public I.7 Other Cl Delia Depth of Grout Seal Type of Grout I I Irrigation —Apnrox. Depth I l Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. _ State Work Dona_ Well Destruction ❑ Well Diameter Staling Material i Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION IX(No septic system permitted if public sewer is available within 2W feet.) _ Installation will serve: Residence^ Commercial Other Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: JU 6 ZA Water table dept, 41 SEPTIC TANK Q Typs/Mfg Capacity 2QJ2j0_ _ No. Compartments PKG.TREATMENT PLT.❑ r Method of Disposal Oistance to nearest: Well 41SJFoundation Property Line_ LEACHING LINE ❑ No.6 Length of lines L km C Total tength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth - Size Number SUMPS LI Distance to nearest: Well 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, and-- ' rules and regulations of the San Joaquin County Home owner or licens3d 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 subcontracting signatN cenifies the following: I certify that in the rformenee of iho-work for which this-permit is issued,l shall employ parsons subject:0 workman's compensa- tion " f1' Pe p Y Pe ! tion laws of California.' - The applicant must call for sit Dire spections. Complete drawing on reverse side. Alm s ned X Titler h u t ! !Uaie: OP 7MENT USE ONLYa-1o Application Accepted by _. s Date Area ~� Pit or Grout Inspection by __ Data Final Inspection.by Date 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 FEE-a INFO AMOUNT DUE OUNT REMITTED CASH CK I R CEiV O BY DATE PERMIVN:0. EM A-211 -