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f APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sari Joaquin County Y for s permit to construct and/or install the cork 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 7 2C 577 AA0Cr0,e_'Z5 City 7 C.t/ Lot Size/Acreage SD X I o o Owner's Name A1o1�21s Add(essr A4 _ Phone Contractor PLO Z) E. C,l-IgD Address N, .gt��l 13c,2T_iQ�J�_License No. Phone Gid -3971 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT iJ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION pSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing it C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing' Specifications _ 1� f'} Public IA Other i-1 Delta Depth of GroutSealType of Grout I I Im9ation _Approx. Depth I I Eastern Surface Seal Installed by I Repair Work Done 0 Type of Pump H.P. State Work Done Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION R(1 DESTRUCTION I i INo septic system permitted it public sewer is J I available within 200 feet.) Installation will serve: Residence_!L/# Commercial— Other Number of living units: _L Number of bedrooms -3 Character of soil to a depth of 3 feet: .4 Y Water table depth SEPTIC TANK. ❑ Type/Mfg t Ca acit P Y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance tonearest: Well f Foundation Property Line LEACHING LINE ❑ No. & Length of lines... Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS IW Depth .-2- �. SizeNumber r SUMPS LI Distance to nearest: Well = Fo'dation /O property Line I g9 DISPOSAL PONDS a I hereby certify that I have prepared this application.and that the_work-thewith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County f 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 tion laws of California." P Y persons subject to workman's compensa- tion applicant must call.for all required inspections. Complete drawing on reverse side, Signed Title: - I1 9 to Date: FO EPARTMENT USE ONLY Application Accepted by �9bmbC� Date Area Ak Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT REMITTED y INFO AMOUNT DUE CASH RECEIVED BY DATE PERMIT'NO. • EEH HU-20IREV.tix5! ©