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� A I � .al y CLi 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 kMIT RES 1 YEAR FROX-RATE 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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,f1 Job Address Rd CityMC Lot Size/Acreage �qG 'Tusc7 .175'yS S• L,yrr�rn,E.es 7.Z�gcy Owner's Name Address' �� L G_. .t rt7/_. _ rjt r sL.�.'.�y e6�� _ -:ZS /'0-E9' Contractor % A ddress 1109' t40�1 6/1 6AGD/C(L�Icense W. VZ200Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �fl4gDTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z - Dia. of Well Casing fD Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �� 1 1"1 Public i 1 Other n Delta Depth of Grout Seal S Type of Grout A917-1 �t7l7f' I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by i Repair Work pone 0 Type of Pump H.P. State Work Done __ ! Well Destruction ❑ Well Diameter Sealing Material & Depth `�} Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is V available within 200 feet.) S Installation will serve: Residence Commercial_ Other kA 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 N PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ll Distance to nearest, Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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(tiring 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 taws of California." The applicant must call for require inspections. Complete drawing onnrreverse Aside,, �// // Signed Title: aa1Z_ a 6)__C A_&g70r/' Date: _S_l16 A70 0 EPARTMENT USE ONLY Application Accepted by Date ~f19 Area Pit or Grout Inspection by If Date Final Inspection by Date ! i Additional Comments: A 0 ` ,&S wd-e- 1, Ve Applicant - Return all copies to: San Joaquin County Public Health "47L Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton. CA 95201 r lFEE AMOUNT DUE AMOUNT REMITTED CASHCK a RECEIVED BY DATE PERMIT'NO. + EN 1126(REV.s n Sl OClk—