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/ - S APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-5420 P O BOR 2009, STOCKTON, CA 95201 1 'EMIT EXPIRES 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 �44(n&„. _„ _ - City me- k.r01✓ Lot Size/Acreage Owner's Name At, Address A,)A-1AAeT_ S!_ Phone Z�b J S-r0C<m0J, C4 �g2Fa3 Contractor Address License No, Phone TYPE OF WELL/PUMP: U NEW WELL ED WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial 0 Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ! CI Domestic/Private. 0 Gravel Pack 0 Tracy Type of Casing Specifications I'I Public El Other f"1 pelta Depth of Grout Seal Type of Grout I I Irrigation _.Approx, Depth L I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ 4 Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Materia & pp Di A 1 1 1 A D TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DE TQC I I I f se y m i f tic sewer is available within 2oQ fey Installation will serve: Residence_X_ Commercial_ Other Permit may have explreQ WA, out 4 Number of living units: _�V_ Number of bedrooms work being completed or inspected f Character of soil to a depth of�3 feet: W e t d SEPTIC TANK 0 Type/Mfg FiE1J2-6a!ACS Capa g mel' � is PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation�' _ Property Line %Q` LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Ll Distance to nearest. Well Foundation Property Line -- ar SEEPAGE PITS 11 Depth Size �� _]�° _ Number SUMPS K Distance to nearest: Well Foundation �. __ Property Line I .,.._ DISPOSAL PONDS 0 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, 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 m st call for all required inspections. Complete drawing on reverse side. '��/ Signed X Title: Date: La—a�/? _ F R RTMENT USE ONLY Application Accepted by Ago Date—1 r r Arsa y +r Pit or Grout Inspection by Date. Final Inspection by Date Additional Comments: _ C4.0 — V, 40- / __ , Applicant - Return all copies to: San Joaquin County Public Health �/yatPR 17 a4A,04-e -5-Yf q Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REM1TrEb CK RECEIVED BY DATE PERMITNO. . EH 13-211REV.1/9 56101 OF EH 14.2E iT -l- i.