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APPLICATION FOR PERMIT 1 3� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROR DA E (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. Lot Size/Acreage Job Address naak*061-- City Address —i A�� - Phone Owner's Name Contractor Address 9N994_=4 �—License No - 'z"� Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of ervice Well Monitoring Well C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CP F] Industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Grave! Pack L7 Tracy Type of Casing Specifications I.1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I i Irrigation ____ Approx. Depth I I Eastern Surface Seal Installed by H.P. State Work Done Repair Work Done U Type of Pump Sealing Material Depth Well Destruction ❑ Well Diameter lir Filler Material b Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 14K REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �D available within 200 feet) Installation will serve: Residence e' Commercial_ Other Number of living units: /--- Number of bsdyooms t Character of soil to a depth of 3 feet: Water table depth r ? No. Compartments Z- ' SEPTIC TANK. �Type/Mfg N�� Capacity ___/ TREATMENT PLT.❑ � Method of Disposal Distance to nearest: Well 1410 FoundationProperty Line 7S LEACHING LINE I {rY No. & Length of lines � V0 Tota! lengthlsize /'X6 r FILTER BED ❑ Distance to nearest: Wellfir!` Foundation /�r Property Line i SEEPAGE PITS , 14-1'Depth 5� r __S4, �(e�r Number SUMPS Ll Distance to nearest: Well ZZS ' Foundation l S� Property Line 96 0 r y DISPOSAL PONDS 0 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 . E Home owner or licensed agent's signature certifies the following: "I certify that in the performance of J4e_work.for which this permit is issued, I shelf 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." %..-J The applic t must call for all "iced inspections. Complete drawing on reverse side. i Title: — Date: Signed X FOR ARTMEN T USE ONLY � I q A 'cation Accepted by Date l q �i Vl�—] Date_l C Ll Final Inspection by Date Pit)Or Grout Inspection -- 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ,7 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 (h�� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO + ,�--{r /� �] ��,�ny� % - /761 + EH 13.2 IREV.tin s) 11 s0� I ! ' U b 3l 20 1��'� ` EH 71.26