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�1 APPLICATION FOR PERMIT i� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE . , PHONE (209)468-3420 + P P O BOX 2009 STOCKTON, CA 95201 r I , EXPIRES 1 YEAR FROM DATE ED 5 (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. 51+9 and $62 and the Rules and Regulations of San Joaquin County Public Health Services. r JL . * City Lot Size/Acreage — [ Job Address . % ,� r tyH a J. '�' ".fi f t-. -- .Phone.Y / , Owner's Name Address Contractordress License N6 Phone TYPE-OF WELL/PUMP: LI NEW WE t + WELL.REPLACEMENT+ DESTRUCTION Ll of Service We11 - ---I- -REP ❑ OTHER Q Monitoring Well L� PUMP INSTALLATIONS-E], F {"e DISPOSAL FLD. k .P DISTANCE-TO NEAREST: ,SEPTIC TANK a EWER LINES ROP. LINE 4 FOUNDATION A RECULTURE-W ` OTHER WELL 6. PITS!_SUMPS '— t INTENDED USE TYPE OF WELL PROBLEM A EA l 5TRUCTION SPECIFICATIONS f t,T 01 Open Bottom © Manteca Dia. of Well Excavation Dia`of Well Casing r r C1 Industrial i ¢ [l 6omestic1private 0 Grave! Pack ❑ Tracy Type-of-Casing .-Specifications I'] Public ' C] Other I l Delta Depth of Groyt Seal Type of Grout r I I Errigation}""=. Y: *Approx. Depth I I E tern utfaca Seal installed by I Repair,WorklDohei U Type of'Pump H.P. -- - State Work Done __ r rSealing Ma rial & Depth ' Well D'eslruction © Well Diameter N-!, Depth- - ' FilleF Mater & Depth TYPE OF SEPTIC WORK: `NEW INSTALLATION tW REPAIRrADDITION 1 1 DES RUCTION I I (No septic system permitted if public sower is # �,z �s > t vailablo within 200 f, t.) + t Installation v�}l1 serve: }Residence— Commercial-�'y -Other ' / i �r Number of living units: Number of bedrooms .� Character sof soil to a depth of 3 feet: INatei labia depth - t -• SEPTIC TANK CI Type/Mfg +� = capacity r No. Compartments �' PKG. TREATMENT PLT. ❑ t Method of Dispos Ta i9 r_ Distance toearest: i Well oundation Property Lina OQU Tbtal length/sire LEACHING�L`INE I ❑ No. & Length;of lines I FILTER 18ED j _11 Distance to,,nearest: Well Foundation Property line SEEPAGE PITS- 7 '" •id Depth -sire _' lumber w % 1 SUMPS " i 1--::Distance to nearest: Well' Foundation _ Prope y Line ' D15POSAL'f?DNDS ,. ;D - 1 i , I hereby certify that I have preps r;ed thii"application and that the work will tie done in accordance with San Joaquin county-btdinances,state laws, and �M-rules-and regulations of the San Joaquin County i f } c I q d -� � E r Home owner or licensed agent's signature cir ifies:the following: "I certify that in the.perfoffnance of the work for which this permit is issued-i-sha11 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 1ho performance of,the work for which fhis permit is issued, 1 shall employ.peraona subjectto workman's compensa tion laws of California." t # ; The applicant usi call for' required • spe.clions. Complete drawing on reverse side. f 1 i1 I Signed' Title: _ w _ Date: b^ j 4k FOi DEPARTMENT USE ONLY } Application`Accepted by �' , Date 0 Area Pit or Grout Inspection;by,.-= Date f Final spection by F Dat y;v,,c " --r 2 ,j 'K !„ r n ` ��'Q ice, Additional Comments: ' ` Applicant - Return all copies to: Sen'lJoaquin County Public-Healtki Services, Environmental.Health'4ermi�t/Services s j g 1601 E.'Hazelton Ave., p 0 Box 200q; SX kton, CA 95201 l l 4 .� ►a FEE' J\1 AMOUkT ❑tJE _ '.AMOUNT REMITTED �1CASNf� RECEIVED BY DATE PERMIT�NO. i INFO, ♦ EM:13-24(REV, H5) { I ..y - ; �(� k EM�� Il ;