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APPLICATION FOR PERMIT IZi3•.d ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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 CountyPublic Health Services. (� Job Address Z/6 �-, _ A -4160t99t S19-C /`,Q V City_144U2/ Lot Size/Acreage Owner's Name1C.t!/ ,f/ �( Address Phone V F 3-Z13 Contractar(:9 yam- Address License No.30Y22 Phon 29-3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.) Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications r `1�'� I') Public 1-1 Other ' n Delta Depth of Grout Seal Type of Grout C 11 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Type P of Pum Repair Work Done U T p _ H.P. State Work Dona_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth i14ZNN Filler Material rE Depth TYPE OF SEPTIC WORK: NEW INSTALLATI EPAIRIADDITION 1-1-•DESTRUCTION I-1-INo septic system permitted it public sewer is available within 200 feat,i Installation will serve: Residence ;Commert lal= Other Number of living units: __i___ Number of bedrooms �7_ Character of soil to a depth of 3 feet: ' - .ter'r, -�di °}.~- �� _.Water table depth SEPTIC TANKe/Mf T Yp g - :Ca!0 e `� '� Capacity- 1 ~€ No. Compartments PKG. TREATMENT PLT. ❑ I i rf'; t Method of Disposal Distance to nearest: WBII w FO ndation 1. � � 1 „ . Property Line .2� LEACHING tlN1w C1�4o. & Length of lines Q �- :Total Iength/size I FILTER BED ❑ Distance to nearest; iWa[I 4M 0 Foundatio .p erty, Line i SEEPAGE PITS' lam[' Depth �t5 � � !size /dfe/•-3��,-� �N�umber� �•Z ` /�� / /� SUMPS 3 ,;,e LI Distance tornearest: Well �0 Foundation_...5�� property'Ltne DISPOSAL PONDS i C1 I r ... .. ,;J, 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:G1 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 sub-contracting signature certifies the following: "I certify that in the performance of the work forwhich.this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." - - The applic st�cal for all req ed in ctions. Complete drawing onA verse side. Signed Title: 9 pate: -- R DEPARTMENT USE ONLY s Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by S _ _ _ fS/�-=- Date t _ I) Additional.Comments: Applicant - Return all copies to: San Joaquin County A Public Health'% -.d Services, Environmental Health'Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE 1 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. INFO CASH l Mar I i EH 13-24(REV.t1Ksi EH 1 4-26 _