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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 j P O BOX 2009, STOCKTON, CA 95201 I I ��RMIT EXPIRES- 1 YEAR_FQ DATE ISSUED. (Complete in Triplicate) t Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i 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. .^rte r Job Address C:Z0/__ � L�'vr-✓ - CitY49A Lot Size/Acreage Al /9C Owner's Name �C f Address Phone Conlraclor �~ l Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION„Q Out of Service Well 0 I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ "61THE R"•❑ 'Mon tor well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP~LINE FOUNDATION AGRICULTURE WELL OTHER WELL-'—Z - PITS/'SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS/ SFE t f--] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - �, Il Public 1-1 Other I71 Delta Depth of Grout Seal Typee.of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by k Repair Work Done U Type of Pump . H.P. -'State Work Done _ Well Destruction ❑ Well Diameter Sealing Materiel & Depth.- L r Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Irr REPAIR/ADDITION l 1 DESTRUCTION-1 I (No septic system permitted if public sewer is t`] 1 ( available within 200 feet.) ._ 1 j Installation will serve: Residence___f Commercial—�JOther - 1 Number of living units: _1L_ Number of bedrooms S Character of soil to a depth of 3 feet: I Water.table depth l0 SEPTIC TANK. c1--Type/Mfg Capacity No. Compartments E PKG. TRE A.T.MFNT PLT. ❑ ve Method of Disppsal l , Distance to nearest: Well ,/, _ Foundation Property Line-449 LEACHING LINE� No. & Length of lines � Tgial length/size ' FILTER-fBEb � ❑ Distance to nearest: Well A5-6 Foundation-_4-2 _Z- Property Line /A SEEPAGE PETS 114-1tepth Size Number r5UMPS Ll Distance to nearest: Well Foundation Property Line /X25 11-Pt� 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 California." Theapplicant ust all f all req ' d inspections. Complete drawing on reverse side, Signed Title: - c_ Date: !✓ f FOR-DEPARTMENT USE-O`NVII--"�-9---"""� Application Accepted by ____ _____ .Date 0/�r` Area .. f Pit or Grout Inspection by Dole Final Inspection bv_2- J Date 1 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! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17"NO. f + 13-24 -7d 4D / �� Q•� i � �v � / of fi'` I �.r