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APPLICATION FOR PERMIT SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES a ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 r EXPIRES 1 YEAR FRPM DATE J fU (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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 1 Joaquin County Public Health Services. Job AddreE5G LAI �� z cre City Lot SS e/A age /25 �� .-r•- � Phone ress � Owner's Name Addc� Pho Andress --," ria Contractor TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service.-Wel-1-3 Cl} OTHER O Monitoring Well l a� 'PUMP-INSTALL'A710N-❑"""-"�'"-""""SY•STEM�fifPAlfi-�7��`-^�-'t a t i SEWER LINES LINEDISTANCf�TO.NEAREST: SEPTIC TANK DISPOSAL FLO. PROP. LINE c Tt FOUNDATION' - ' AGRICULTURE WELL .QTFiER WELL ' ,...� PITS/SUMPS 'sir I 6 INTE-NDED USE TYPE OF WELL /'"PROBLEM AREA CONSTRUCTION SPEC�FICATIONS .�� 1 Dia. of Well Casing F1 Indusirial ;` --i -. ❑ Open Sotto p Manteca,,__. ia, of WeIITExcavati_on9 ___ Cl Domestic/Private., ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a I _. � f'1 Public r'` is Other F1 Delta Depth of Grout Seal Type of Grout ` I I trriUation _ Approx. Depth I I Eastern Surface Seal Installed by I rState Work Done Repair Work Done 0 \ ype of Pump H,P• h Well Destruction ,❑ Well Diameter, Sealing Material & Depth ir _ Depth- - 'Filler Material #, pth t I TYPE OF SEPTIC WORK: NEW'INSTALLATION I I REPAIR/ADDITION Y, DESTRUCTION I I INo septic system permitted if public sewer is (� available within 200 feet.1 J 1 Installation will serve: Residence Commercial— Other" I Number of living units; .Number,of=bedrooms.+— - t Character of sail to a depth of 3 feet: Lea , -- i._:51 flNp� ; -Water table depth S. T3r �� No:Cirri• rtrnenis'_'".�`. I SEPTIC TANK.�� ❑ 'Type/Mfg CapBbiC�i F r PKG, TREATMENT PLT. ❑ ". Method of Disposal ! Distance to nearest:# Well dation �'"- ' � Property-Line LEACHING LINE No. & Length of lines Total length/size FILTER SED C] �Distance to nearest: Wel :�....._. Foundation _ 'L Property Line a 1 � b! t Number ' } SEEPAGE PITS l Depl h S /`Size - _ - -- I SUMPS LI Distance to nearest. Well - Foundation -� Property Line tZ�G7 - I ;k DISPOSAL PONDS ❑ �'_ X 4I hereby certify that I have prepared tliis application and that the work will done in accordance with San Joaquin county ordinances, state laws, an � I rules and regulations of the San Joaquin County ' Home owner or licensed agent's siretu" nifies the following: "I certify that in the performance of the work for which this permit is issued, I shah not employ shy person in such manneras to become$u6jectTt wo orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certifyAat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawsiof California." The applicant must calor all required nap • tion4. Co plate drawing,on reverse side. # t i Date: sem- Signed � Title. i s F t t I j FOR'DEPARTMENT USE ONLY Applicatioh Accepted by Date f yy � Area _04 Pit or Grout Inspection by Datefi - Final Inspection by Date i l � i T Additiortial Comments:-• _..-._. _ ' Applicant-,Return all copies to- San Joaquin County Public Health •.t Services, Environmental Health Permit/Services f + i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i FEE AMOUNTPtJE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT NO. _ - - - - �: t' .�._ . .....__... INFO.. 9 r r• Ell 13-2iIREV.1/"5i �� i r