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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 0 BOX 2009, STOCKTON, CA 95201 HERMIT EXPIRES ]._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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ' 44Lf Uja_J 0_" RO City M +07 T"eC_ ,t of Size/Acreage 4 0 �✓�f Owner's Name f' -6'e"'r Rpt(TA_fAddress .j?4s—&— -s ILP. Phone ` " 2C 12- Contractor ZContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� 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 C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public El Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth [ I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ r Well Destruction C) Well Diameter Sealing Material & Depth V� Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 14—'—DESTRUCTION i I (No septic system permitted if public sewer is t r Installation will serve: Residence ' �Commercial,.__._ Other available within 200 feet.) k Number of living units: ___L Number of bedrooms Character of soil to a depth of 3 feet: 5 A-t) 4" . Water table depth SEPTIC TANK. 0;-*-Type/Mfg L. G wtj C.r"e-T '� Capacit "Za �J y__,f______y___. No. Compartments PKG. TREATMENT PLT.C1 Method of Disposal Distance to nearest: Well 5/_ Foundation 0 Property Line t 60 — O� Hr ILfACHING LINE�eC � Xf❑ No. & Lengs /� Tptal length/size ILTER BED (=Y Digtance to Well sp--� Foundation 1 f� _ Property Linel d • 4� 0$4 DNe cC id " )e t! S SEEPAGE PITS 14 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepir6d 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 must c I for all rtlquired inspections. Complete drawing on reverse side. k Signed Title: J _. Date: FO DEPA TMENT USE ONLY Application Accepted by Date ��/� ea Pit or Grout Inspection by Data Final Inspection by • Dete/ L` 7 Additional Comments: Y Applicant - Return all copies to: Sam Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y DATE PERMIT"NO. INFO EH 13.24IIIEV.iimsiIsm EH14.26 o ta' `�