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APPLICATION FOR PERMIT _ a SAN`'JOAQUIN COUNTY PUBLIC HEALTH SERVICES + ENVIRONMENTAL HEALTH DIVISION IS ON &1&0"5111 t� Ot 1.601 E. HAZELTON AVE. , PONE ( ) �0 i -�r P 0 BOX 2009, STOCKTON, C i xv ! PFAMIT RES 1 YEAR FROM (Complete in Triplic Application is hereby made to Sap Joaquin County for a permit to const and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ ��"� �' I � ti�1�4 City ��X' 014 Lot Size/Acreage's Owner's Name Address ALJ Phone Contractor 'EST fr AL"A Address RAtx1tL. CO2QYOA CA c'514?- License No. :35`5_1 Phone l� i y7L r_ TYPE OF WELL/fbf0P NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION . Out of Service Well ❑ v?, PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK AM SEWER LINES 1Q0'4-__ DISPOSAL FLD/P("* PROP. LINE A! ` � FOUNDATION _ _.Sd ^ AGRICULTURE WELL �_ OTHER WELL 22' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECT CATIONS N 00ndustrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing nv Specifications t I'1 Public g Other p.tow,Tt-etn�F1 Delta Depth of Grout Seal Type of Grout t I Irrigation ZLZZApprox. Depth I 1 Eastern Surface Seal Instal Repair Work Done 0 Type of Pump H.P. to a Work Done _ G� Well Destruction PC Welt Diameter y - Sealing Material 8 Dept Depth X32 Filler Material b De -� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1.1 DES R T N I I [No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence— Commercial W cher Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth L SEPTIC TANK 0 Type/Mfgr No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell Foundation Property Line LEACHING LINE 0 No. 8 Length of fines Total length/size FILTER BED ❑ Distance to near st: II Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS L.1 Distance toa st: Well Foundation Property Line IJ. DISPOSAL PONDS O I hereby certify that I have prepay -this ap lication and that the work wM be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaqui unty Home owner or licensed agent's signature ifies 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 1he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica must Cellrad required inspections. Complete drawing on reverse side. _ {; . �LLP Signed (((((( ` Title: SYA FF r`�t+.�� - - Date: , DEPARTMENT USE ONLY n Application Accepted by ' �'�`' Date ////J/9d Area �3 Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH • EM 1341[REV.I/Rsl