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APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION A601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i 22MIT 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 14,td/ City _7' Lot Size/Acreage 14C.8,FS f F f Owner's Name _1LAL S.A.r/ ASS&C.1A7L�SAddress Pd 6e7X 9S- '. 5 .✓ Phone j f Contractor rLar/D G. &jeo Address AD 41-Be'-.7 A License No. �u3' Phone k TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Ik PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 t` + n Industrial i ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ' ❑ Tracy Type of Casing Specifications- -- I'l Public i_1 Other 11 Delta Depth of Grout Seal Type of Grout ^ I I frrigatinn Approx.Depth I I Eastern Surface Seal Installed by Repair Work Done LJ T p P Type of Pum H.P. State Work Done.— Well one ._Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is V r available within 200 feet,I r Installation will serve: Residence___ Commercial Other ,fi t�- (� V Sr. I Number of living units: t NumberFof bedrooms V Ilan Character of soil to a'-depth of 3 feet: C L A v Water table depth SEPTIC TANK. ❑ Type/Mfg L Capacity—Lk-&— No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal r -rt: r sP Distance to nearest: Well `r S'961.2f_-Foundation- Property Line "2-0 r LEACHING LINE +' ❑ No. & Length of tines Total length/size 4 FILTER BED ❑ - Distance to nearest: Well Foundation Property Line f SEEPAGE PITS r•—,, Depth r Size tot?r� Number �- I SUMPS 1 ..i LIw:.Distance to nearest: Well _ 1 CO't" Foundation 367,' _ Property Line .2 r DISPOSAL PONDS ❑` 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 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: "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.." t ' The applicant must call for all required insPe.ctions. Complete drawing on reverse side. Signed X Title: Date: &a` FOR DEPARTMENT USE ONLY Application Accepted by !� t Arlt-� Data Area Pit or Grout Inspection b/yDate Final Inspection'by _ Data �Z Additional Comments: l�i° t l� ^r Applicant - Return all copies to: San Joaquin County Public Health Services, Fnvironmental,Health-Permit/Services I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 i INFOFEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DA E PERMIT N0. i EH14-�IREY.t/M5) �� r