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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, STOCKTON, CA 95201 PERMIT 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .� Job Address ?Sao A l City Sze: _ Lot Size/Acreage Owner's Name hi. // ! Address- fa- t�✓ Phone Contractor it Jeer�Lat :5" Address-1-0,21&A n &A ;/j &62.�`rr�kraOL3 License No..2Q 4'�� Phone TYPE OF WELL/PUMP: NEW WELL C] 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 f V M Industrial ❑ Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing lJV C:] Domestic/Private -) Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public E Other 171 Delta Depth of Grout Seal Type of Grout I I Irritlanon —..Approx. Depth I I Eastern Surface,Seal Installed by Repair Work Done 0 Type of Pump H.P. 1 State Work bone _ Well Destruction ❑ Well Diameter Sealing Material rE Depth nom_ Depth I Filler Material & Depth TYPE OF SEPTIC WORK: NEW.INSTALLATION REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is ! available within 200 leei.l Installation will serve: Residence Commercial Other Number of living units: __L Number of.bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK J;' Type/Mfg--- 11- AaCk3stC Capacity No. Compartments : L PKG. TREATMENT PLT. ❑ 1Method of Disposal Distance to nearest: Well -ro Foundation /d Property Line /D LEACHING LINE [Je No. & Length of lines .2-- g.�` Total length/size r FILTER BED ❑ Distance to nearest.' Well Sn-� Foundation � Property Line 10 SEEPAGE PITS J)r Depth Size Number SUMPS El Distance to nearest: , ' .Well Foundation lir " Property Line fns' DISPOSAL PONDS ❑ 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 cenifies 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 becbme 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 must all for all repo' ed inspections. Complete drawing on reverse sido:� �.r 2- Signed X Title: �,a,� Date: FOR DEPARTMENT USE ONLY If Application Accepted by - �t—� Date 'D Area V Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: r 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 y FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INF , PATE PERMIT N0. N EH 13-24 r EH t`24IttEV.t/nsl -70, t —Ar� �f /Q _ --7 9o