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APPLIdXTION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 ce urs fe PERMIT EXPIRES 1 YEAR FROM DATE I,SSUVn f (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 grade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. / Job,Address! P v- City l� Lot Size/Acreage f Owner's Name Address 1"AZOP ��(/ Phone Contractor &��_Address Z_1ra^eLicense No.39 2D- I Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C] Monitoring Well L7 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 C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications XS iblic Cl Other n Delta Depth of Grout Seal Type of Grout I I Irri0alion —.Approx. Depth t I Eastern S ace Seal Installed by Repair Work Done K Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION III INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg ""Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size O FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 C�st ornia." The applic call for all requir sped' s. Com to drawing onrse side. Signed Title: _ / Date: FOR DEPARTMENT USE ONLY —1 n f Application Accepted by Data 7�7 -_9 Area I Pit or Gout Inspection by Dots Final Inspection by � 5�7�- Date Additional Comments; 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT'NO. INFO c� CASH . EH 1321[AEv.rix5r ��vv �� —7 5;-qV IqO- 17 EH 21-26 •� V l