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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 � NT P 0 BOR 2009, STOCKTON, CA 95201 Ivel, C(apy SEP 0 3 1�9 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) SAID! JOAQUIN CCll,lAj-.r r PUE1f.IC j�LA[_rN „ Application is hereby made.to San Joaquin County for a permit to construct and/or install t�f�INk(lc�}`��l�i��e C bggd.' This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reguiattib k�' 'San Joaquin CountyPublicHealth Services. ` /� ^ Job Address '/�j U Iyot-1h f) (6 y1 `,-t r-e el City II��t A Lot Size/Acreage 4", /6-QrQ-- Owner's Name �� ol v�Q v i� Address I%� k�OX ?e&( �� a hL�C ICt fry C705-1 Phone 7� 5 l�'(I� Contractor Stlt'l�'� ��"✓ Address4 SG 53`� Si4�� ZI-YtBIi�I'c License NoAT7000 Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ �WI SEWER SINES 4:�: VQ'r DISPOSAL FLO. /100' PROP. LINE 2-0 FOUNDATION U+ AGRICULTURE WELL Zi—CA!OTHER WELL�` PITS/SUMPS �.1o� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r fl Industrial ❑ Open Bottom J9 Manteca Dia. of Well Excavation'`' rr Dia. of Well Casing I I Domestic/Private O Gravel Pack E] Tracy Type of Casing 10y Specifications SCN I'I Public JR Other fl Delta Depth of Grout Seal 5 r Type of Grout C6/t'IkgVr I I Irrigation .3-!C'Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 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 Character of soil to a depth of 3last: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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, 1 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 applic ust CoKfor all required inspections. Complete drawing o reverse side. ` + '^ Signed X Title: I�� Date: FOR IRT M E ONLY Application Accepted by 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 95201FEE INFO AMOUNT DUE AMOUNT FIEEMIITTED CAK RECEIVED BY DATE 9P/ERMIT'NOO. . EH1324(REV.rins1 EN'41-26