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F APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTION .AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT XP RES 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 County Public Health Services. Job Address Szf&4.4�,7_,VL I City iJ1�Lot Size/Acreage �C Owner's Name p Address Phone /� �' Phone Contractor �� Address- h f! � /t'�2ZY—� License !V . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ I SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1 DISTANCE TO NEAREST: SEPTIC TANK ^SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 'INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`l Public fa Other fl Delta Depth of Grout Seal Type of Grout i 1 Irrigation Approx. Depth I I Eastern _ Surface Seal Installed by Repair Work Done U Type of Pump II.P State Work Done ^- C_ i; a_. . Sealing Material.&,Depth ell Well Destruction ❑ WDiameter I �, r i Depth Filler Material & Depth [(1 TYPE OF SEPTIC WORK: "NEW INSTALLATION r i REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is r available within"200 feet.) Installation will serve: Residence L Commercial 77 Other'" �. 1. Number of living units'' V - Number of bedrooms A y 1 1 Character;of-soil to-a if4M of 3 feet: '^ �� t�� lJ -{" Water table depth SEPTIC TANKType/Mfg Capacity - _ No. Compartments PKG.,TREATMENT PLT. ❑ Method of Disposal A Distance to nearest: Well '`1t Foundi tion '�"� Property Line LEACHING LINE No. & Length of lines , Total IengthJsize _ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Sire Number ' SUMPS I l Distance to neareit:-` We4L• Foundation ,Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this appiicationyand 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 work an's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work forwhic_h this permit is issued, I shall employ persons subject to workman's compensa- tion laws'of California."' The applicant must call for II r fired inspections. Complete drawing on reverse side.'- - Signed X enrer Title: Dale: I ; FO AT T USE ONLY Application Accepted by - "Date Are Pit or Grout Inspection by Date Final Inspection by s r . .. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1:• .. 7FEE AMOUNT DlIE AMOUNT REMITTED CK RECEIVED 8 _ DATE PERMIT'NO INFO f EH 132{IREV."�iK51 9 ]h EH i{-26 1-7 17,10 •o