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i :+ APPLICATION FOR PERMIT ., SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM ED (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 i Joaquin County Public Health Services. 3 f0 J7�r i lCity Lot Size/Acreage y Job Address I CHEW-,LYn1 - ltT� Address S' 19/" 00- Phone Owner's Name S"o0 2 S*'� C7? ' 0000 U k�f-3 1� 9141 7 Contractor 9Lur7-4 Z ddress e No.� a Phone TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT (1 DES Cl Out of Service Well ❑ SYSTEM REPAIR ❑ OTHER Monitoring We PUMA INSTALLATION ❑ ��DI��R2/n�G-��(e DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N_ NO INTENDED USE TYPE. OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Dia, of Well Casing Industrial Cl Open Bottom 0 Manteca Dia. of Well Excavation 9 [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Type of Grout Il Public 1-1 Other f l Delta Depth of Grout Seal 1 1 i Irrigation - —Approx. Depth t I Eastern Surface Seal installed by C Repair Work Done 0 Type of Pump H.P. State Work Done Sealing Material & Depth ^dW� � Well Destruction ❑ Well Diameter Depth Filler Material & Depth TYPE.OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION 4 I INo septic system permitted it public sewer is . - available within 200 feet.) 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 O Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line �P a U SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 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 ad pplicant l call for a spections. ompiete drawing o verse side. Signe life: Aub Date: � - FOR DEPARTMENT USE ONLY r j Application Accepted by Date g� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: r �ez� S3-o-t7 , r 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE 1'ERMiT'NO. INFO / �/ 9/ lose l a EM 13-24(REV.i/n 5) U / �� /' 070 q, L r —los EH 14.26 r t..tT