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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 1 ApplIcation is hereby madato 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. iP . it Lot Size/Acreage Owner's Name C ' Wit,ZifEZI Address ,?? 4:4- ,p2.364/' Q 4Fy.345-7 Contractor v e... . Address License No.20'572/ Phone (4:1012.'4X-4 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 , • DESTRUCTION 0 Out of .Service Well 0 o PUMP INSTALLATION 0 SYSTEM REPAIR 0 - OTHER D Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS --, INTENDED USE TYPE OF WE 1(j PROBLEM AREA CONSTRUCTION SPECIFICATIONS •---- . 0 incustrial 0 Open Bottom 0 Mantat7 Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ,..' 0 Gravel Pack 0 Tracy Type of Casing 'Specifications' I'l PuOlic '-(. Other - n Delta Depth of Grout Seat Type of Grout I I trrillation Depth I I Eastern Surface Seal Installed by '- __Approx. Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well-Diameter Sealing Material & Depth Depth Filler Material Si Depth TYPE OF SEPTIC WORK: NEW INSTALLATION) REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is .... available within 200 feet./ . Instaffation-w111-serye:—Residence-Commercial—Other il C \ Number of living units' _at_ i Number of bedroo s "3 4 -,. a. Character of soil to a depth of 3 feet: ],.-C. ...._i — Water table depth .3d f 1'-/ 6 eY4, TANK 0 Type/Mfg I I 4 r't Capacity /- '4. A 06 No. Compartments 2-'''' I,.' SEPTIC / .1- it2.1..___.1 1 , Method of Disposal PKG. TREATMENT PIT. 0 i ?eh C (r i Distance to nearest: '.j ilAtell., Foundation I / 61 ( Property Line ils-f , _ ,.. 1 I 47^, cr 1_47.71_.. _... -J-- i i -4, . ._ LEACHING LINE " I 1, sr d,.... _ti (?'" No. & Length of lines ' -3-'-'4' 2,-1H f 01. 0 Total lengtz' e C"'". - recf," i i ( FILTER BED 0 Distance to nearest: Well 4,46,a- FoUndStion /6 • '• , Propert,ZLine 5- ( I i • 3-• I . \ SEEPAGE PITS 11.1 Depth Size I ' I ' 1 • • Number SUMPS LI Distance to nearest: Well I Property Lihe- . ;F:42; tlint ' . DISPOSAL PONDS 0 ta- . ,(.., - t / - V ------........,. Horns owner or licensed agent's signature certifies the following:'"I lit.) that in t i1 performance of the work for which this permit is issued, I, shall-nOt I I I employ any parson in such manner as to become subject to workman's compensatiorpaws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which thisfpa:rmit is issued, I shall employ Wirsons subject to workman's compensa- tion laws of Califorpla." The' applic4 Iitf call for all r iredpections. Complete drawing on re Signed I . Application 'Aecepted by Pit or Grout Inspection by Date t Final _Inspection by 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 AG (Complete in Triplicate) I hereby certify that I have prepared this application and that the ork'cviIibe dweiin i1C-cordance with San Joiczerin county ordinances, state laws, and rules and regulations of the San Joaquin County / 1) ;Side. 4)e4 I / Date' DEPARTAXENT USE ONLY Date 7- 1 Area 2 3 gy EH 13-24 IREV. 1,ns EH 14-26 FEE INFO 91 AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT NO. 119 PI) I n 60 , , * 141 tY1 E . i- io - `II q12