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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 O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FRQM DA ED (Complete in Triplicate) 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 Services.! Job Address . 12212 �. /SETS L /l714AJ- !_AJ City 4D pl __ Lot Size/ reage Owner's Name DO A) eV/mow/A© Address �� Phone Contractor_ Gtr yD lrJmis� Address 7 A.1, No.4 t 774 Phone '32'71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER © Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump H.P. State Work Done �. Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 4� TYPE OF SEPTIC WORK: NEW INSTALLATION71 REPAIRIADDITION I 1 DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other Number of living units: 4— Number of bedrooms_ R Character of soil to a depth of 3 feet: _ s A A1T7_5C__ LO��►'t Water table depth SEPTIC TANK. ❑ Type/Mfg P9L- Capacity.-1-2--0-0— No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -5-W foundation 75D Property Line_ .S42 LEACHING LINE No. & Length of lines -3 -40, Total length/size r✓ZO V FILTER BED ❑ Distance to nearest: Well syraf Foundation 3 6 Property Line �O SEEPAGE PITS I Depth �.S/ Size~ Number 3 SUMPS L1 Distance to nearest: Well Foundation . f w e 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 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_C_ Title: G/ f Date: �— Z FOR DEPARTMENT USE ONLY A Ii inion Accepted by Date 2 Area at 2' Ptt r Grout Inspection by 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMiT'NO. . EH 13-24 PIEV.r1Nsl EH 14-2e