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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E C E V ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 MAY 1 1400f) P O BOX 2009, STOCKTON, CA 95201 ENVIRONMEN'i AL HEALTH kF M[IT EXPIRES_ 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete is Triplicate) Application is hereby trade 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 _�5�r _M13�Y.a _ City MAi43ng" Lot Size/Acreaget��1_AsTE. Owner's Name _744kmnit�r.Dt, t mnt3&47 Address SAr1N4__' _ Phone ;LCA) ESJl-'A111,310 Zagl rltt,a nl.,r� 4 Ha. P� 1t t S Contractor GR£[-xCa "D _ Address k-v-CALJQ, 4 A 94 'Jn License No.(-5485lbSphone (9 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — 9 b' DISPOSAL FLD.�_ PROP. LINE —I / FOUNDATION a-5� AGRICULTURE WELL t�•la OTHER WELL, PITS/SUMPS LLA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial ❑ Open Bottom anC it taco Dia. of Well Excavationes r Dia. of Well Casing E.) Domestic/Private rave[ Pack ❑ Tracy Type of Casing 'PV L Specifications ['i Public Cl Other ❑ Delta Depth of Grout Seal 1A- 13_ ____ Type of GroutSVjA'_ F�t.L.- P I i Irrigation aoApprox. Depth 13 Eastern Surface Seal Installed by WJ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well DiameterT Sealing Material & Depth }� "Uo �r Bff=h r- . Depth -30 Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOiTION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED 111 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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- tion laws of California." The applicant must call for all requi d inspections. Complete drawing on reverse side. Signed x ��aC t��a ,�a4,v�Title: yr f Date: - 5-4 F EPA T USE ONLY Application Accepted by Date A sa /7 Pit or Grout Inspection by at Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CA3Fi RECEIVED BY DAK 8TE ' PERM17' INFO r EH 3-70EV.I N 51 EW 41.26