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4 APPLICATION`rvR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 ?/ P 0 BOX 2009, 'STOC%TON, CA 95201 PERMIT FIRES 1 LEAR FROM ,DATE ISSUED I (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Seevices.1� �} Job Address L__/__ _- - /i(/ C".rp_,A!�2 City o!PLot Size/Acreage Owner's Name � C-!_.GJJ�. Addre55 ._. 67_�� Phone Contractor Y c5 ddress a2o i�-r��C�License No, &M�6 Phone TYPE OF W :W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ Monitoring Well PUMP INSTALLATIOf�- SYSTEM REPAIR p OTHER ❑ L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i 4 INTENDED USE----'"`TYPE OF 1NELL_ PROBLEM AREAr CONSTRUCTION SPECIFICATIONS ` i rl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation" Dia. of Well Casing (� Domestic/Private Gravel Pack Q-Tracy : � - Type at Casing- - off- Specifications FI Public I. Other i !-1 Delta Depth of Grout Seal T pe of Grout I I Irrigation Approx. Depth I I Eastern u ce Seal Installed by Repair Work Done U T of Pum H.P. — ` Type p State Work bone -Well Destruction.---0.-,_Wel! Diameter. Sealing Material i Depth Fili&-&terial d Depth t P TYPE OF SEPTIC WORK: NEW INSTALLATION I F� REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 1_' . .1. available within 200 feet.l s- ti Installation will serve; Residence"`Comii bYcii l- ,.., Other t i I Y Number of living units: ,.Number of bedrooms g Character-of soil to a depth of 3 feet: f Water table depth "+ SEPTIC TANK., ❑ Type/Mfg Capacity No. Compartments . PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line rr LEACHING LINE Cl No. & Length of lines. Total length/size FILTER BED SLI Distance to nearest: Well Foundation Property Line i � f ( SEEPAGE.PITS I I Depth Site r Number SUMPS '`LI Distance to nearest:, Weil Foundation r- Property Line DISPOSAL PONDS p a ` ( + I hereby certify that I have prepared this apphcation'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 . •'...- w — _7 ; 1 s Home owner or licensed agent's signatu'r6 certifies the following: "I certify that in the performance of the•work for which this permit is issued, I shall n employ any person in such manner as'to become subject to workman's compensation laws of California." Contractor's fiihing`or sub-contracting signature.. certifies the following: "I certify that in ttwped r fiance of the work for which this permit is iisued, I shall employ persons subject to workman's compensa- tion laws of California.":.- The alifornia.":.The applicantI al equir ons. Complete drawing on rra�vve sa side. � I � ms j Signed r 7iHe �! _ •% Date- { ' FOR;DEPARTMENT USE ONLY f Application Accepted b Q^� PP p y I .Date 1 0 Area Pit or roti nclion-by'.,/ f ! at `_Final Inspection by Date, ' c n ^ Additional Comments: ] Applicant— Return all copies to: San Joaquin County'Public-Health . - - � _ Services,'IIivirotitoerital'33ealth•Perna t/Services • ��'- �'� - _ - - � k 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 + S FEEAMOUNT DUE AMOUNT REMITTED CK' 5{RECOVEp'BY DATE .PERMI1'N0. INFO CASH,' ?: ` ♦ EH 13-24(REV.r/Ksk d �� EH 14.26 •i i