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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-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 coupllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City 5 � Lot Size/Acreage Owne('s Name D.4RXELL /51,9WAMA/ Address SA S _. _-_ Phone Contractor FLQya S. lwe_ ) - 1 Address 7N• .4bg948,6.4_PT"A41Z License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT FJDESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM PAIR ❑ ` ' . OTHER ❑ – Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OiSPG.SAL FLD. PROP. LINE FOUNDATION GRICULTUR ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM REA CONSTRUCTION SPECIFICATIONS n Industrial CJ Open Bottom 11Manteca Dia. of Well Excavation Dia. of Well Casing —� Fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q� Il Public [D Other /n D Depth of Grout Seal Type of Grout l� I I Irrigation Approx, Depth I ( astern urface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth cc Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITIONX DESTRUCTION t I INo septic system permitted it public sewer is available within 200 feet.) ,gyp Installation will serve: Residence_ Commercial ✓ Other _ C P v fj•L/G X74 /�+� Number of living units: Number of bedrooms _M1W MAX Character of soil to a depth of 3 feet: -jL4X T _„ _ Water table depth a� SEPTIC TANK Q Type/Mfg Capacity o. Compartments Z A re .tis y PKG. TREATMENT DLT. ❑ �-/Z00 GAC .C/Fs`7 7" o��'.r�',u� �� Method Of Disposal Distance to nearest: Well N Foundation PropertyLine LEACHING LINE L-) No. & Length of lines Total length/size sa X 4�7 FILTER BED Distance to nearest: Well /✓ Foundation Property Line SEEPAGE PITS 11 Depth Size Number! SUMPS LI Distance to nearest: Well Foundation 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 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 must call for all required inspections. Complete drawing on reverse side. Signed X Tom' _ Title: 6Date: S`1' Fy' T ORMRTMENTUONY Application Accepted by Date ^ Area Inspection by Date�� Final Inspection by Date '/Z—71 Additional Comments: 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 FEE INFO AMDUNT DUE AMOUNT REMrf�TTED ASH RECEIVED BY DATE�f }� (P�ERMIIT'�N7O. EM r EH A-IREV.1/"5)