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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 BOR 2009, STOCKTON, CA 95201 SC �! PERMIT EXPIRES 1 YEAR FROM SATE ISSUED XD (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 1862 and the Rules and Regulations of San Joaquin County Public Health$Services. Job Address ` City Lot Size/Acreage „Z ///�C� Owner's Name Zr�'c� ��'' S� _ . .. Address --- -- Phone 33 [ 0 Contractor Z yt--_ AddressT' l License No.30Y.7'Zl Phone{, 16 ZfS/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out 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 F1 Domestic/Private - 0 Gravel Pack - ❑ Tracy Type of Casing Specifications F1 Public ,I-1 Other 171 Delta Depth of Grout Seal Type of Grout I t Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done T Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADOITION 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: __L_ Number ofedroonls Z Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK Gk—Type/Mfg VC Capacity 610 No. Compartments L PKG. TREATMENT PLT. 0 ` / Method of Disposal Distance to nearest: Well Foundation �� Property Line 0 1 LEACHING LINE L9r No. & Length of lines i:1 40 .� Total iength/size FILTER BED 0 Distance to nearest: Well s Foundation 3p r Property Line !5� f +� SEEPAGE PITS Ii-I—Depth '7 Site b _ Number Z "1- SUMPS I_I Distance to nearest: Well 5"� `Foundation- 7 S Property Lirie IS, DISPOSAL PONOS ❑ 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 i r 1 Home owner or licensed agent's signature certifies the following: "I certify that in the pe.riormance.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." F , The appli n .must call for all requt din ctions.Complete drawingxon reverse side. Signed X Title: (9'c<IAJC4 _.......__ Date: t� I FOR DE ARTMENT USE ONLY -3-7/ Area Application Accepted by Date _ � 3 _ or Grout Inspection by Date �Final Inspection by- U".UDate f Additional Comments: b 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO, . EH13-2�IREV.rin51 0,-0 J a�O� �9�r2V2 r3r�j(� �U�Oti[�5 EH 71.26 7 / — f�-/