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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION int. r 1601 E. HAZELTON AVE. , PHONE (209)48$-3420 ' P O BOX 2009, STOCKTON, CA 95201 PERMIT E121RES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) Application is hereby mads 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 � � CLt1 y city��+� �. Lot Size/Acreage Owner's Name �-Z;L A4A+i{',.' Address Phone Contractor Z W. f t�r�,. y/z"C Y j Address. No -1m.12a Phone/~AX*.ZAL-?'e'7Sc TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT "1w - -DESTRUCTION O Out of Service Well Cl 'Y✓ PUMP INSTALLATION ^ SYSTEM REP R L? OTHER C] Monitoring Well U I DISTANCE TO NEAREST: SEP'f!C'MANIC" -SEWER LINES DISPOSAL FLO. PROP. LINE ;"VOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS iN T"ENDED USE ' t TYPE OF.WELL` PROBLEM AREA CONSTRUCT ION SPECIFICATIONS - 0 Industrial 4.0 Open Bottom C Manteca r Dia. of Well Excavation Dia. of Well Casing : 1;1 • v,. f:l DomesticJPrlvata a0 Gravel Pack; Jv, I." Tracy Type of Casing .Specifications - f I1 Public - 11 Other fl Delta Depth of Grout Seal Type of Grout i i Irrigation —Approx. Depth I i Eastern Surface Seal Installed by n Repair Work Done U Type of Pump H,P, j State Work Dona Well Destruction 0 '',Well Diameter `° Sealing Material i Depth # • Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i ' REPAIR/ADDITION DESTRUCTION i I INo septic system permitled it public sewer is ;1 -1 _. available within 200 feetJ Installation will serve. Residence Commercial..r. Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © T ` ype/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.D ' _ _ _ Method of Disposal 4~ti I Distance to neareat: •Weil foundation_____ Property Line f. LEACHING LINE � �No. 8 Length of linea � � � Total Iengthlsiza � FILTER BED 0 Distance to interest: Well -r f Foundation l — Property Lina ✓fy . SEEPAGE PITS 11 Depth5ite - Number SUMPS LI Distance to nearest: Wall l foundation Property Line r DISPOSAL PONDS O ��7U f 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 I rules and regulations of the San Joaquin County I 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 parson in such manner as to become subject to workman's compensation laws of Cakfornia."Contractor's hiring or subcontracting signature I 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 compansa f tion laws of California." The applicant must call for ail required inspections. Complete drawing on reverse side. 1 Signed ' Title:.'tA- Date: r FOR DEPARTMENT USE ONLY4141 " Application Accepted by Date L L C_ A," Pit or Grout Inspection by Date Final Inspection by Date } Additional Comments: # Applicant - Return alt copies to: San Joaquin County Public Health Services, Pltvironliental Pealth Permit/Servicei 1601. E, Hazelton Ave., F 0 Boz 2409, Stockton, CA 952201 N AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"Nb. Eli 13-74 ttlEv,i,As)