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APPLICATION FOR PERMIT f; 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-3420 ZT' P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) 4 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 anj 1862 and the Rules and-Regulations of San Joaquin County�Public Health Services. `J/4 f? MAY �� Job Address f -� 1 1 3DoZ City Lot Size/ crea.ge r� Owner's NameAna Tf 117f r ,�.'! 1QQ5 .,.__.,_. Phone 31 ' i. Contractor , ., -,rpss�-Sc��,� Address ��License No. � 1 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well. ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 1�—DISTANCE TO NEAREST: SEPTIC YANK SEWER LINES ��— DISPOSAL FLD. """'-PROP. LINE y��,,�y� (( ^ _t FOUNDATION �� AGRICULTURE WELL qW_' OTHER WELL PITS/SUMPS j INTENDED USE T)�Pt OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION f a n Industrial Fropen Bottom C3 Manteca Dia- of Well Excavat_iot. S Excavation pia. of Well Casin y Type of Casing—11�P� h I,I Domestic/Private 0 Gravel Pack ❑ Trac ^_ r Specifications iblic C7 Other Delta Depth of Grout Seal r Type of Grout rigation ttM.l.Approx. Depth I) Eastern 5urfac6 Seal Installed by 'pair Work done U Type•of.Pump H.P. State Work Done ' Well Dest ction ❑Well Diameter ' Sealing Material-& D,ethe 0 ❑ iub Filler Material & Depth v i 1 ' TVP OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I OESTRUCTION I I (No septic system permitted if public sewer is r available within 200 feet J f t Installation w e: Residence �'Comme�cial_ Other �1 Number of living units: Number of bedrooms r i c hara`ctet cif--soil-to-a-depth of-3 feet:- ' Ater table depth SEPTIC TANK. ❑ Type/Mfg ` ' Capad No. Compartments r PKG. TREATMENT PLT. ❑ 8 Method of Disposal Distance to nearest: i t s 4 ' cam. We Foundation Property Line S 11 LEACHING LINE C1 No. & Le of lines $ A Total length/size �. FILTER BED ❑ D' nce to Wear's[: Well Foundation Property Line S SEEPAGE PITS I I Depth Size _ Number �J SLIMPS LI Distance to nearest: Well Foundation Property Line �} AL PONDS D -- 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 j } i } ° Home owner or licensed agent's signature certifies the following:al " cariit Y 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 workm"an's compensation laws of California," Contractor's hiring or sub-contracting signature I 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 Theapplicant us all for all re aired i pections. Complete Idrawing on reverse side, k Signed { JTitle'" _ „_- Date: Wiz—!9�V OR_DEPARTMENT USE ONLY - Application Accepted by Date Area rr� r Pit or Grout Inspection by _ ata- r Final Inspection by Date '! F Additions! Comments: Applicant - Return all copies to: San Joaquin County Public Health t Services, Environmental Health Permit/Services F I 1601 E:'Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 LFE AMOUNT_DUE.f .. AMOUNT.REMITTED ....CK _. D-BY -- PATEPERMIT-Np:CASH'EH4iIIREY.17 I - r_A'...i..'. Q_- .-- - __92T -��J. _ F 7