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ru APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 s P O Box 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRPM DATE ISSID (Complete is Triplicate) Application is hereby made.to $an 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 Y41YL0A- do City �^G Q/ Lot Size/Acreage i jOwner's Name EiR27`A V4!rAddress S� -�2 Phone F. ContractoriWIA^_- C �t�.�'Address i VK/7 License No.sy4s73—Phone 7 TYPE OF WELL/PUMP: ANEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION 0 SYSTEM REPAIR lW OTHER ❑ Monitoring Well ❑ I 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 i r F C-) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I"1 Public Cl Other 171 Delta Depth of Grout Seal Type of Grout I i Irrigation —,.Appfox, Depth I I Eastern Surface Seal Installed by Repair Work Done * Type of Pump _yce a_ H.P. State Work Done Depth & De t M Sealing Material p Well Destruction ❑ Well Diameter Sea Depth f Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIR/ADDITION I l DESTRUCTION l 1 (No septic system permitted if public sewer is . ?11 available within 200 feet.) Ir Installation will serve: Residence_ Commercial . ..Other k � Number of living units: Number of bedrooms __Ja 4- ,".g .,�� O Character of soil to a depth of 3 feet: � I Water table depth SEPTIC TANK. ❑ Type/Mfg -Capacity /No Compartments PKG, TREATMENT PLT. 0 ..� _ ,Method of Disposal f Distance to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. 8 length of lines Total length/size l f FILTER BED _ ❑ Distance to nearest: Well Foundation Property Line J J [ SEEPAGE PITS -yI l� Depth ` ' Size -'` Number I SUMPS LI Distance to nearest: .. Well Foundation Property Line -- DISPOSAL PONDS [} '� ` 1 f 1 t "f ► - ?. 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 applicant mu call for all required inspections. Co plate drawing on reverse,si e. ^7'` Signed Title: �� / D�4'�- Date: (0—�✓`�'-21 1 PARTMENT USE ONLY Application Accepted by Ilk. Date1,¢ /� Area /J Pit or Grout inspection by Date Final Inspection by .% / / '�/�Gc Y nee / i Additional Comments: r Applicant ^ Return all, copies to: San Joaquin County Public Health t t Services, Environmental Health Permit/Services IF 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEk INFO AMOUNT DIE AMOUNT REMITTED CK CASH AEC61VEO BY DATE (] J_PERMIT'NO. EH A-21(REV. /H 51 ��•� �/\ t/ - I „, •-1 l `�1 �� EH 7 .Za i