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APPLICATION FOR PERMIT SAN JOAQUIN^COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BO%, 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 compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. i G , Job Address to L City Lot Size/Acreage �0 Owner's Name Geo T I r"G y d Address 0 2 P Ae zcl Phone Contractor Z! "" 1 Address - � License No. ��.,'1•Phone TYPE OF WELL/PUMP: •11, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service,Well J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well ❑ ll 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 CONSTAUC710N SPECIFICATIONS f_1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing- Specifications I'1 Public ,Cl Ocher n Delta Depth of Grout Seal` Type of Grout 11 Irrigation L ��Approx. Depth I I Eastern t':Surface-Seal Installed by % .; Repair Work Done 13Type�of Pump 't•~ � H.P �a•'r State Work Done _ Well Destruction ❑ WellDiameter Sealing"MAteiW & Depth Filler, Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i~I DESTRUCTION I I INo septic system permitted if public sewer is I` ,,/ available within 200 feet.) Installation wilt serve; Rasidence,_ Carrimercial— Other Ntfmber of living units: I� Number of bedrooms Character of soil to a depth of,3 feet:` -`� Water t8l;e depth I , SEPTIC TANK ❑ Type/Mfg -_� ' __ Capacity'' No. CompartmaSh� ts'l. O PKG. TREATMENT PLT. Cl �N '. ) 3` Method of�Dlsp sal ti•l• s """ Distance fo nearest: Well; Foundation) �� Property Line LEACHING LINE v Na. i length of lines s 1G Total length/size FILTER BED a Distance to nearest: Well !2e �,:F-oundatfAn. - Property Line ^-' I jA SEEPAGE PITS { I Depth _ Y`+ ° ' Size-- — — Number -- SUMPS E1 Distance to.risaiesr.F; Welt Foundation Property Lina' j DISPOSAL. PONDS D I hereby cartify that I have prepared this application'and that the work will be aane`in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San, Jdaquin 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 maniier `as to becoms subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ceRlfies'ths following: 'I,certify that the performance of the work for which this permit is.isoued, I shall employ persons subject to workman's compensa-tion laws of California." ' The applicant must call for all r u{red ins ctions. Complete drawing on reverse side, i �.If Signed.XTitter- o ! ' Date: ,- a I: 1f F DEP L � f -Application Accepted by Date Are Pit or Grout inspection by " Date Final Inspection by Datr Additional Commentsr : i. ^' Applic'nt.- Return all copies to: Sab'Jbaquin County Public Health y a _ I Services, ,Environmental-Health Permit/Services �. ? r`^.•. II .r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ' i FEE CK , ` INFO MOUNTtDUE AMOUNtT'.f EMIT7Eq. T CA`SH6�` --VRECEIVED BY DATE PERMIT'N0, ♦ EH'13=24111IN:-t!N'SI "..'._" _ .�..'.�• -'lO.0 �....,C - '!"'•-- -" �„_.�_ -C/.�f \.J�J ,«.,.�.-. - EH 1426