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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-5420 t P O BOR 2009, STOCKTON, CA 95201 i kEMIT EXPIRES 1 YEAR FROM DATE ISSUED i D �� (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 186 and the Rules and Regulations of San Joaquin County Public Health Services. r I Job Addresslzt City Lot Size/Acreage 9/9, Owner's Name dra r!t T. Phone – a Contractor s, f ( itense No./ :2 Phone 4:3110 qF_ TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public I] Other i-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ^ k Installation will 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 EKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well1AP_19_nound11ion�8 Property Line LEACHING LINE ❑ No. & Length of lines _ 4i� � �,_. Total length/size i FILTER BED (_) Distance to nearest: Well-ZM,0 Foundation Property Line SEEPAGE PITS 11 Depth ! ize ;-' �. Number SUMP 0 Distance to nearest: Well L'12490 ``F-oundation.. �— Property Line DISPOSAL PONDS ❑ - 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 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 csrtifiss 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 must call for all req ' d inspections. Complete drawing on reverse side. r Signed X Title: � /I -� Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date �` � AreaAV Pit or Grout Inspection by Date Final In pection by :62&0_A13 Oatff Additional Comments: S Sl n. r pfd Applicant – Return all copies to: Ban Joaquin County Pub is Health Services, Environmental Health Permit/Services a 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE r INFO AMOUNT DtJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I Sao '7/ t