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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ° ENVIRONMENTAL HEALTH DIVISION 11] 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 IT EXPIRES I YEAR)-FROM DATE 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. /V.4kPAPA /voBz1V C.-s7; rcF 0 I=fz a�' A `d PY Job Address / O S C�tr/e 1 City ? ,/ Lot Size/Acreage i �' 1 _t]wner's Name - _ -N lV S1nlA- Address ` > ~�`� 'c Phone Contractor �L Address t i1►z?eel License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ t WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of,Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ f 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 F] Industrial EJ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing C.7 Domestic/Private ❑ Gravel Pack 17 Tracy Type af'Casing Specificationt s I'} Public Cl Other C-I Delta 'Depth of-Grout Seal Type of Grout I I Irri{ialion —.Approx. Depth I I Eastern -Surface Seal 'Installed by t Repair Work Done L7 Type of Pumpi H.P. r ` '• A1. State Work Done j Well Destruction ❑ Well Diameter Sealing Material & Depth- i Depth t Filler Material &'Depth' i DI TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADTION I } n DESTRUCTION I I lMo septic system permitted if public sewer is P f available within 200 feet.) r Installation will serve: Residence 1,'Commercial_ Other' s' f Number of living units: -I-- Number bedrooms � � 4 j Character of soil to a depth of 3 feet: I -+ Water table depth ` SEPTIC TANK. #O Type/Mfg a` °16 C40 6,AL �•',. -Cap ity <An No. Compartments 0 PKG. TREATMENT PLT. Ll !�'r Method of Disposal t Distance to nearest: Well 'Goundation/ ^T Property Lina7-F7' LEACHING LINE 0 No. & Length of lines _ `` "' "` Total length/size ,?d FILTER BED n Distance to nearest: Well i Foundation -;Property Line SEEPAGE PITS )4 Depth ` _Sire- Number _ J SUMPS r 0 r Distance to nearest: Well ourilation% Property Line- DISPOSAL ineDISPOSAL PONDS © I hereby certify that i have prepared this application and that,46'work will ba done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i r s f Home owner or licensed agent's signature certifies the following: "I certify that in ttte 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'shali employ persons subject to workman's compensa- tion laws of California." ,The applicant must call for al requir d inspections. Complete drawing on reverse side.` , r i q• p Signed X # Title: ,. �-f� :Dai t -- ---- e: d FOR DEPARTMENT USE ONLY I' { Application Accepted by t Date 9~�� U, _ Area tt or rout Inspection by Date cl— Qnal Inspection by Date ZLl� Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Y a Services, Environmental Health Permit/Services , 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 . F,EE. _AMOUNT DUE --AMOUNT REMITTED--- --r CK if_ . -"—RECEIVED BY DATErvPERMirf NO. INfO CASH._-. ` � 1 + EH 4.20(ACV,i/r st EH i4.16 �•-