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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, STOCK-TON, CA 95201 lO PERM1_ 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address 2'3 r 'r0 L 1} City Lot Size/Acreage Chevron 0.5AZne- Address �Y/) Cgmino �gmdh'-�Qh rnP one( O Owner's Name vs ' [� r 1 DI¢!�lKG X33 Ertl , o Co VG G 57 S -f Contractor `t._ V�SUe1 Address ��QO �' +'�- e� License No.��?-SOB 9 PhonelF DC7 �� 158 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT _ ESTRUCTION ❑ Out of Service Hell ❑ l w,� PUMP INSTALLATION ❑ SYSTEM REP9IR ❑ OTHER Monitoring Well o/ - DISTANCE TO NEAREST: SEPTIC TANK `~ SEWER LINES _ DISPOSAL FLD. �" PROP. LINE *7/57 ; FOUNDATION AGRICULTURE WELL 4 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'I Public 1-7 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx!Depth I I Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth A Filler Material & DepthLJ�� _ Clsink 7vid skrrr �1 TYPE OF SEPTIC WORK:. NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.l + Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:f Water table depth ` SEPTIC TANK. ❑ TypelMfg` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Me� Distance to nearest: Well Foundation Property-Une RE - - - LEACHING LINE ❑ No! & Length of lines Total length/siz AN 2 7 19-92 FILTER BED Cl Distance to nearest: Well Foundation - Pro"J%QWN C TY ' 1 0111.7r_In i 1rni T11 nrnv36 rn SEEPAGE PITS 11 Depth Size Numl:ENlrrC?ONMENTGI WEAl Tu DWICION SUMPS LI Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS © I ' 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." The applicant rr}yst call or required inspections. Complete drawing on reverse side, Signed h/ tier ��b/s G/S�- Date: { ~ R DEPARTMENT USE ONLY Application Accepted by Date { Pit or Grout Inspection by a Fingal Inspection by Date Z Additional Comments: v�� Applicant - Return all copies to: Saar Joaquin County Public Health ' Services, Environmental Health-Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 r ✓r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �q/ CASH EH 13-241AEV.rinse EH 14.2E i