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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 i P 0 BOX 2009, STOCKTON, CA 95201 3 - i - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to Sat 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. L4 do 1 Job Address Soar— �YL ©et City�f_ Lot Size Acres Owner's Name �' h `� Address r Phone i Contractor t7 ' n0 Address 2 c License No._0g015/ Phone 7 ,TYPE OF WELL/PUMP: NEW WELL / _ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well 0 PUMPwINSTALLATION U `SYSTEM REPAIR ❑ OTHER ❑ -Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 1`�a z`r— SEWER LINES DISPOSAL FLD. !"` PROP. LINE 3� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r 0 Industrial Open Botlom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I vDomestic/Private ❑ Gravel Pack 0 Tracy Type of Casingie,t_ Specifications l'i Public [:1 Other h1 Delta Depth of Grout Seal � Type of Grout„ — I I Irrigation -._Approxi Depth t Eastern Su ce Seal installed by O 1p'rr Repair Work Done U Type of Pump H.P. State Work Done { n Well Destruction ❑ Well Diameter Sealing terial & Depth Depth t Filler Material & Depth 1 + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is rt available within 200 feet.I, f 1 Installation will serve: Residence I Commercial— Other Number of living Number of bedrooms a' Character of soil to a depth o ' ' f Water table depth SEPTIC TANK. ❑ Type/Mfg '` 3 Capacity No rtments �.r k PKG. TREATMENT PLT. 0 L.f Method of Disposal ! Distance to nearest: Well a" Property Line LEACHING LINE CI No. & Length of lines Tota size FILTER BED D Distance to neo Well Foundation Property Lt J SEEPAGE PITS epth '' Size Number SUMPS Ll "Distance'to nearest:" well._- Foundation —Property Line DISP ONDS CI 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 I 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 subcontracting signature certifies the following: '9 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." i t The applicant must c II for all required ins ctions. Complete drawing on reverse side. r Signed X Title: A344Z Date: � - I7 r QO I DEPARTMENT USE ONLY ��f 4 Dateri----�=--- Area Application Accepted by -- i Pito rout nspection U x M1 Dat Final Inspection by ��1-°1 � - Data tz.�LG Additional Comment l � Applicant ^tReturn all copies to: San Joaquin County Public Health `f , Services, Environmental Health Permit/Services " 1601 E. Hazelton'Ave., P 0 Box 2009, Stockton„CA� 95201 FEE AMOUNT DUE AMOUNT REMITTED CK#JRECEIVED BY DATE PERM11'N0. + EH' INFO CASH 13-24tRE1+.tinsi i 003`A r L `ate. 3 d , 16 Tom/ �`% lj EH 44-26