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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 s-1 (0 P O BOX 2009, STtOCKTON, CA 95201 „PEJITEXPIRES 1 YEAR FROM DATE 5SUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i 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. XJob Address �"' �' �" A f P7 City _5 r 14� • Lot Size/Acreage #, 3 1 Owner's Name FR Gb /�IARCHAAtD Address _�5_04 & 11741 n Phone C131 82-T_ Contractor b L�t'1 a+r2 Address .s i,+Pn6 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ W L REPLACEMENT -. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ YSTEM REP R ❑ OTHER ❑ Monitoring Well Sail, a+r-" y DISTANCE TO NEAREST: SEPTIC TANKi SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE EL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO13LEM AREA CONS UCTION SPECIFICATIONS 0 Industrial D Open Bottom ❑ Manteca Dia. f \Grut allvation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack 0 Tracy T e of Specifications ( {�, I'1 Public CI Other n Delta epth oeal Type of Groutt I Irrigation ._-._.Approx. Depth I 1 Eastern Surfacealled by C Repair Work Done L7 Type of Pump f H.P. State Work Done Well Destruction ❑ Well Diameter Se. ing Material & D_-_p_h Depth f ller Material & Depth YPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is available within 206 feet.) Installation will serve: Residence._ Commercial_____ Other Number of living units: � Number of bedrooms 3 Character of soil to a depth of 3 feet: a __Water table depth •✓ r SEPTIC TANK. d Type/Mfg , _ 'e�Sr" j-- Capacity l�Od G r' No. Compartments �* PKG. TREATMENT PLT. ❑ f r Method of Disposal . r I Distance to nearest: Well L,L�-+ Foundation Property Line _i�___ • i EACHING LINE ❑ No. & Length of lines _ ar Y S Total length/size r � t t 1LTER BED ❑ .Distance to nearest: Well�- Foundation�� Property Line 3 SEEPAGE PITS 11 Depth _ � Sizet Number SUMPS Ll Distance to.nearest: Well 2V0 Foundation Sit Property Line POS PONDS ❑ 1 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 Cbunty Y 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." ' I The applicant st call for all required inspections. Complete drawing on reverse side. Signed Title: Date: _4~� - - i FOR DEPARTMENT USE ONLY Application Accepted by Date kA��-" Area Pit or Grout Inspection by i Date Final Inspection by Date i � Additional Comments: t o .. I Applicant - Return all copies to: San Joaquin County Public Health Services, Ftvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE 9 INFO AMOUNT DUE AMOUNT REMITTED /CK H RECEIVED BY L/ DATE � [PERMIT'NO. � . SH13-24{REV.1/n5i �r6� 70- 01 kqq 1 ✓o~ ` � 10— y EH t42e