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APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I I -RERMIT EXPIRES 1 YEAR FROM DAIE ISSUED I (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 _ 10 ID Ak rtV 614_& Road City 1'fo4 f ea—a Lot Size/Acreage/-2d Owner's Name #1 ASS il dfe8 Address JOD- &JncA�ge #aWye6&- Phone -239-1758 Conlractor �6 �ddress ' l%dj e- (t71r/�� N License No.4;f rtePhone Z r S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Servibe Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ! i Il Public 11 Other n Delta Depth of Grout Seal Type of Grout j I I Irrigation _ .Approx. Depth I I Eastern Surface Sedt Installed by Repair Work Done 0 Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth Q TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.i 0 Installation will serve: Residence ''I Commercial,____ Other Number of living units: 4— Number of bedrooms Character of soil to a depth of 3 feet: )-CAMP, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ A Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size i FILTER BED K Distance to':nearest: Well Foundation� Property Lina v(0 1 SEEPAGE PITS 11 Depth Size Number SUMPS EI Distance to!,nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 Joe juin county Home owner or licensed agent's ' ?tura 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 man r as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the f to g: "I t e 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 C t-or a��l " r E{ f The applicant ust required inspections. Complete drawing on reverse side. C� Signed X Title: .. Date: o FOR DEPARTMENT USE ONLY Application Accepted by Date h4lq� Area a, Pit or Grout Inspection by Data Final Inspection by — Date �D 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 AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE: PERMIT'NO. ` .t + EM 13•24(REV.tin51 4 EH 1426 0