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APPLICATION FOR PERMIT t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 f P 0 BOX 2009, STOCKTON, CA 95201 PRUIT EXP RES 1 YEAR FROM DA E rrn (Complete in Triplicate) Application Is hereby made to San Joaquin C, o—ty for a permit to truct describe . Thi application is made in compliance with San Joaquin County-OrdinancenNo. 549aanda1862sa.nd theeRules andworkein Regulationsdof Sans k Joaquin County Public Health Services. !f Job Address O4 "5. AAJ_—y y '- City Lot Size/Acreage Owner's Name . 1 AJ 42•OM E11 N PP r 86:&y"/F(Addiess, -263J G?. /� 3 _ 010 Phone Contractor L-A),?-0 A , x ddress it/ /!�F/.age ?¢jr ei License No, 7TYPE OF WELL/PUMP: a NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKC7 S ER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AG CULTURE WELL THER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AR CONS TR ION SPECIFICATIONS ( I L) Industrial ❑ Open Bottom ❑ Manteca Dia Well Excavation �M r C} Domestic/Private 0 Gravel Pack y - ❑ Tracy Dia. of Well Casing Pe ai Casing ' , 1'1 Public I-1 Other 1- Specifications (� Datta De h of Grout Seal Type of Grout I I Irrigation . Approx. Depth I I,Easiar � ! Suria a Seal Installed by Repair Work Done 0 Type of Pump ^_ ''H:P �-- Well Destruction O Well Diameter r Sealing'Materia & Depth State Work Done_ a # 3 Depth Filler Materiiil,dr th � L` f TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A'DD1TION I f DESTRUCTION I,1 (No septic system permitted if public rawer is O Installation will serve: Residence Commercial s Other / ailable within 200 feet. ! -' Number of living units: Number of bedrooms,_ Character of 6011 to a de�pth �p /►of 3 feet: 5A SEPTIC TANK: LYS hType/Mfg c • 'P Q_i W t table depth tPKG. TREATMENT PLT. 0 Capacity—J-1--c 0 No. Compartments ",.2— ( Distance to nearest: Well 00 ' Method of Disposal- 1 - _ Foundation ^ Property Line LEACHING LINE No. & Length of tines — O3 FILTER BED Total length/sire SU ❑ Distance to nearest: Well Foundation a 0 ` r ! 1 Property Line ` SEEPAGE PITS Depth W k 1 9 Sire f' Number € SUMPS LI Distance to nearest: Wei 1— �d'� � ! DISPOSAL PONDS ❑ — —1---Foundation ^�a`-7�_� Propem,_Line- t '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— Homo owner or licensed agent's signature certifies the following:"i certify that in the performance ofJthe work for which this permit is issued, i shall not employ any person in such manner as to became subject to workman's compensation laws of Califo certifies the following: "I certify that in the performance of the work for which this permit is issued, I hal emola Contractor's hiring or ub-contracting signature tion laws of California." p Y 1]erson subi o workman's compensa- i The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title. �.-,.-�..�.� pate: FOR 40.tARTMENT USE-ONLY Application Accepted by n Date Area of Pit Grout Inspection by i Dat "? Final Inspection b Irn Date dditianal Comments: , Y Applicant _ Return all copies to: San Joaquin County Public Health Services, &vironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE ' OU T REMITTED CK INFO MPERM17, + EH 13-21 rREV. CASH RECEIVED BY DATE r i x sJ rr��