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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete iu 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 D� City 49,10 Lot Size/Acreage Owner's Name r " �� -- Address Q Q !�/9 R�� Pho 6`� JD1C�E� �r/�iP.d�/ qd�F.�.l Ca.PF' �%1��,��-ti✓.-��.�� p.�,f%✓�,�.� �9�sG7o �� ro��P-�'.� 7' Contractor r ST��Q � STG �rAddress �2J l t� Z) tMO License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1 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 F..I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public I-1 Other n Delta Depth of Grout Seal Type of Grout i I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by" Repair Work Done U Type of Pump H.P. State Work Done Well Destruction rams Sealing Material & Depth CBM9"�+� Tlvv/T 4cp Depth Filler Material & Depth 0 �l v TYPE OF SEPTIC WORK: ALLATION f I REPAIRJADDITION.61- DESTRUCTIOt s , !No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ _ Commercial — Other Number of living units: Number of bedrooms n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (� PKG. TREATMENT PLT, ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total iength/sire FILTER BED ❑ Distance to nearest. Well Foundation Property Line r SEEPAGE PITS 1 1 Depth Size - Number SUMPS LI 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 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 applica m all for ZZ ad ins ctions. Complete drawing on reverse side, Signed X Title: �'U1�SULTi��7�Date: Z 1. F -ONLY Application Accepted by TL �s Date U o n fee y Pit or Grout Inspection by Date Final Inspection by Dat o Additional Comments: Applicant - Return all copies to: Sen Joaquin County Public Health Services, Environmental Stealth Permit/Services f 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 INFO CK 41 FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EM 13-14 IAEV.riH51 —� S EH A-26 re Or 0