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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 BOR 2009, STOCKTON, CA 95201 PERMIT 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��rr Job Address Z.Z , ..�cf --_/ / fes-,z City /1 1) Lot Size/Acreage 1-10 Owner's NameP11 r� R /('Address l� /civ /V /71/ Phone A Contractor Address License No. Phone TYPE OF WELT./PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 E Industrial D Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications I'I Public 1-7 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation �.Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done 0 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 I REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) s 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 L. No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well 54 Foundation Property Line LEACHING LINE L'_ No. & Length of lines yD T?tai length/size FILTER BED D Distance to nearest: Welles Foundation _ Sa Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: WelIS-L Foundation 16 a> Property Line DISPOSAL PONDS Cl 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 subcontracting 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 ust call fo all uire inspections. Complete drawing on reverse side. Signed X Title: CX�Z Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 3— 0 A or Grout Inspection by Date Final Inspection by �` Dat$ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 lFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'N0. + EH 14-26 EH 1 3-24(REV.t K 51 , © /' r o q L�7�