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Zwr) "O APPLICATION FOR PERMIT ,,,• o i` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH <DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 : r j1T EXP RES I YEAR FROM D 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 Lot Size/Acreage I - -- - -• � .t.:!- _ -_ _. - _ _ - . , City`��.L 1C, � _ _ _ Owner's Name 1 S Add e s �! 4 ��`" ,) �•� t '; Phone r Adtlres� ��v .1.. / �Q1(,r� �. Contractor (cense No �•�-�phon TYPE OF WELL/PUMP:- NEW WELL,❑ WELL REPLACEMENT CJ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLp, PROP. LINE FOUNDATION__- ,AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL f PROBLEM AREA CONSTRUCTION SPECIFICATiONS�) C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E F Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications— I') Public 1-7 Other 1-1 Delta Depth of Grout Seal Type of Grout yk I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ 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 REPAIR/AD UITION^DESTRUCTION 17 {Ido septic system permitted if public sewer is Installation will serve: Resides e ` Commercial er available within 200 feet.) Oth �___,_` _ t Number of living units: �_ Numb p44,f bedrooms - I Character of soil to a depth of 3 feet: t or ❑ Typ 4 SEPTIC TANK. `eYMfg 49 4'0 Water table depth t _ r • " Compartment Capacity fdo.Es , PKG. TREATMENT PLT. C3j'' '� !. ' Method of Disposal ; -Distancelto nearest: Well— _ i r ' + Foundation property Line --t ! t LEACHING LINE No. & Lengthiof lines _ © s Tota! length/size I FILTER BED t 1;� pistanctf to nearest: Well Foundation �C1 _ Property Line SEEPAGE PITS I I Depth Size ---------------------- Number 1`y tSUMPS Distance.'to neLrest: Well Foundation ' 1DISPOSAL PONDS ❑ y Property Line n� } I hereby certify that I have prepared this application:al_+ that the work willrbe done_il.accordadce_with_$an_Joaquir*i_county.4rdir,ances'_state laws, and f rules and regulations of the San Joaquin County ��- ' Home owner or licensed agent's signature certifies'th fa�Idwin 1 employ an t q - a g: "I certify that in the performance of the work for which this permit is issued, I shall not P Y Y person in such mariner as_to},b$come subjeb.t 16,workman's compensation laws of California." Congectoi s hiring or sub-contracting signature Certifies the following: "Lcertifythat in the performance of Iha,work for which this permit is issued, !shall em Io tion laws of California.'[ , R y Persons subject to workman's compensa- a i The applicant must call for all required iri ctt ns.-comp) a-dra ung on FSigned Title., Date: .+ '•d i r k ' FOR DEPARTME1?4 ',;uu ONLY Application Accep�d by +r - - �__ to _' l l Y• =ma �.N, —Area- Pit or Grout Inl4iion by 1 pate Final Inspectby ,1 / ,• �. r a. _R. ,-s•. tioion n b Date--- ;Additional Comments: r Applicant -Return ell copies to: San Joaquin County Public Health r _ y: w ._ .. a I Services,- Environmental`Health Peri dt/Ser-vices - LL 1601:E. Hazelton Ave.;-P4'O Box 200 9,r Sto�ktori,..CA 95201 FEE ~•_ r r . I AMOUNT DUE AMOUNT REMITTEDCK -(NEON ti OSP RECEIVED BY DATE PERMIT•NO. EH 1J-211REY,ISA 5! 4 EH t14-26T a r._Ob 7 i�-I ,' , b Qr�'4Jf�e �l ;