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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 CountyPublicHealth Services. , J Job Address .11J-357 �e-" /►tQ• L't+�r-. City 4-eac/t 0_ -- _ _ Lot Size/Acreage Owner's Name __z_ z fir h Address,_klA x - Phone Contracto,J,XL., 04.,44 Address !a License No.AJ!22)J[7 Phone -7X '1n1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well (7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (�, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0'1 C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing {W [I Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications �1 f'1 Public [I Other n Delta Depth of Grout Seal Type of Grout I i Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by r• N Repair Work Done 0 Type of Pump H.P. t State Work Done Well Destruction ❑ Well Diameter Sealing Material &'Depth Depth Filler Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.l 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, 0 Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE No. & Length of lines ~ - '"Total 14angth/size FILTER BED n Distance to nearest: Well ---X4J*` Foundation /0" Property Line I0/ SEEPAGE PITS I* Depth .2-]m _ _Size Number SUMPS LI Distance to nearest: Well Foundation Property Line f0 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 subcontracting 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 Title: �"A _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `� Area Pit or Grout Inspection by Data Final Inspection by 4i"/d''t�i t� pate 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 95201FEE / INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 7 DATE PERMIT'NO. r EH 13-24IREV.I/HSI I�'�10 z� If— —f T�7o -��n + EH 74-28 C fr 1 [ir/