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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PFJWIT EXPIRES 1 YEAR FROM D TE ISSUED (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. sy Job Address O City f' Lot Size/Acreage T OAcyp r368-OZp3 � r h Address _1,J" -7 3o i J-a�4l Tgge- Phone l Owner's Name � .� r� 7 5� hs T 7z"-9b Contractor Address 0--9057 Va IQ ;icen�oe N-o. 'S�1 1 S�/2 Phone TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION t of Service Well ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring:Well `❑ DISTANCE TO NEAREST: SEPTIC TANK O 4- SEWER LINES �" DISPOSAL FLD10'0 PROP. LINE FOUNDATION -O AGRICULTURE WELL OTHER WELL PITS/SUMPS P iNTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /P n Industrial ' x pen Bottom ❑ Manteca —Dia. of Well Excavation Dia.of lh/eli Casing r J i1 [I Domesticl-Private ❑ Gravel Pack 0 Tracy Type of Casing _ Specifications I'I Public Cl Other Ll Delta Depth of Grout Seal _ 1o0 • __ _ Type of Grout F " Irrigation YMpprox.°Depth I I Eastern Surface Seal installed by-` � — Repair Work Done ❑ Type of P p H.P. State Work Done�� d — Well Destruction Well ameter � � Sewing Material &`Depth f to_ 16S Filler Material.& Depth �/C �I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION (J DESTRUCTION I I INo septic system-permitted it public seweiris available within 200-.feet.i f installation will serve; Residence_{ Commercial_ Other ra Number of living units: Number of bedrooms 't I i i Character of sail to a depth of 3 feet: Water table d 1 SEPTIC TANK. ❑ lype/Mfg Capacity No. Com menta .r PKG. TREATMENT PLT. ❑ ry Mat of Disposal (�, Distance to nearest: Foundation Pfope Line LEACHING LINE CI No. & Length of . as Tot ength/size FILTER BED ❑ Distance to arest: Well Foundation Property Lined SEEPAGE PITS 11 Dep Size Number SUMPS U stance to nearest: Well Foun ion _____� Property Line {Q� h DISPOSAL PONDS �} I hereby certify that I have prepared this application and that the work wilt 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 performancb*bfAhe work for which this permit is issued i lshall not employ any person-in such manner as to become subject-to workmen's compensation-laws of California:- Contractor's tilting 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 - L tion laws of California." The applicant a require ins s. Complete drawing on rave se side. r SignedMc _Title: _ Date: FOR DEPARTMENT USE ONLY • ! Application Accepted by Date `�Z-90-_ — Area E Pit or ro t Inspection by Date Final Inspection by-�� / _ Data Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental.Health,Fermi t/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED INFO CASH EH 13-24 ME 1�� EH;x.26 (f