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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISIS lL'.ED_ �� (Complete in Triplicate) Application is hereby made.to Sen 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address LIZI r r 05 City Lot Size/Acreage Owner's Name Address _Y'JcXri j2o-jghRCk S hone Contraclor ��+7��tJ-Yr► CA orc. Address Kae_ License No.�_ ,►t1i2s1,Phone_ -�7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER O Monitoring Well � DISTANCE TO NEAREST: SEPTIC TANK n4 SEWER LINES _hl DISPOSAL FLD.ha- PROP. LINE .12�06 FOUNDATIONJJQ -- AGRICULTURE WELL OTHER WELL_L�E_'� PITS/SUMPS a' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r� Domestic/Private ''Gravel Pack ❑ Tracy Type of Casing PVC. Specifications I'1 Public 1-1 Other .--r Delta Depth of Grout Seal Type 1 of Grout 6=c- C,menl_ 1 1 Irrigation -LQ!,Approx. Depth I I Eastern Surface Seal installed by� 101 r�C13161!R`DTl Repair Work Done ❑ Type of Pump H.P. Sta a Work D ne Well Destruction © Well Diameter Sealing Material & Depth ami Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION 1 I DESTRUCTION ( I lNo septic system permitted if public sewer is available within 200 feet.) Installation wilt 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 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 n employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur certifies the following: "I cenify 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 required ins ctions. Complete drawing on reverse side. Signed x Lisk_�-'- L^ at.�-� Title: .CA.9 1 #=- 36SIZZ- Date: (�&1� �,,��-� ,, D/ FOR DEPARTMENT USE ONLY Application Accepted by �V�yl.rCL..� Date l �� Area ZYr Pit or Grout Inspection by &&a" Date Final Inspettion by ✓t"' — Date?ZL r r Additional Comments: r 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 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. r EH 13.21 1REV.1/x S) g q OC) �goj 2"'1