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APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 _2ERMIT 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. Job Address -- t-0_ux-1-L __ City 5-k"t')t') Lot Size/Acreage Owner's Name ` � 1-J!J Address Sy�L�-L^ Phone f 'z'2 r r ��11 Q q(��^Q ,I Contra Oress �2-570 License No v 11 Phone -/ 7 J u TYPE OF WELL/PUMP: YNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLpry PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL; '"°PttTS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE CIFICATIONS � ' F1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation iia. of Well Casing Cl Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing specifications 1'I Public 1.1 Other 171 Delta Depth of Grout Seal ` 4ype odGrout II I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by .,,.,.. Repair Work Done L]- Type of Pum Sealing State,Work Done _ Pump � 1 Welt Destruction -`-❑ Well Diameter ng Idaterial & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADIDITIONA DESTRUCTION l Ik:(No septic system permitted if public sewer is available within 200 Met) --&- —Installation—Installation will serve: Resf -idence : Cornmercia!� Otl'iei Number of living units: _._L___ Number of be roo s_ Character of soil to a depth of 3 feet: SEPTIC TANK. Water table depth ❑ Type/Mfg tf Capacity No. Compartments PKG. TREATMENT PLT, ❑ i Method of Disposal Distance to nearest: Well U Foundatiori Property Line LEACHING LINE D No. & Length of lines 561 TO/at len th/size ` FILTER 8£D ❑ Distance to nearest: Well Foundatio roperty Li�„� � SEEPAGE PITS 1 1 Depth f7 r Size Numbel SUMPS Distance to nearest: Wel! Foundation F roperty Line DISPOSAL PONDS ❑ 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 ownei 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 j 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: "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 app4icanust all to nspeetions. Complete drawing on r verse side. 4� Q Signed Title: Date: r t7 190 _ DEPARTMENT USE ONLY 7l/�(��/ Application Accepted by �' Da[e`WL�--�--fi--1� Ar a Pit or Grout Inspection by Date Final Inspection by Date `7 r�z 5 �Q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �: .rtiz: FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT�NO. {� INFO 'n• CASH �r Q .„.;EH13-24tREV.+ IRS 1 �� G( '^'0 'Q JLQ� 1446 L �L t to -: