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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ��6 Zp-�1�_ Z8 PER1dIT EXPIRES 1 YEAR FROM DATE_ ISSUEDED /-GYM r (Complete in Triplicate) I 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 ServlceB. 1#3091V 0S_/_ 3/0 13 Job Address _ � � �� 7 � Rn. City Lr C Lot Size/Acreage � auc i�[SIJatP /Op Caox LIZ3-7 Phone 36 Owner's Name 17 STk f.! _________ Address T i - ContraciON505 ►UA91'ess 45*1 ice nse No. urLZ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 9 Out PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -•P FOUNDATION AGRICULTURE WELL OTHER WELL 9"AI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fiW7-1G+ DOLy F] Industrial ID Open Bottom 11 Manteca Dia. of Well Excavation KDL` Ea Domestic/Private ❑ Gravel Pack f ❑ Tracy Type of Casing Speeifieetietwtr�-- -- I'I Public I:) Other n Delta Depth of Grout Seal I I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Welt Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.M 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. ❑ 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L) 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 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 compensa i tion laws of California." The applicant nwal call fo gquired insPections. Complete drawing on reverse side. Signed X Title: �1 � • ��g5oZZ56/S7— Date: Y= —C? FO >rPARTMENT USE ONLY Application Accepted by Date Q Area Pit or Grout Inspection by Date Final Inspection by / Date _q'G i 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 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH .241REV.iiHsl i4� EH 26 I