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APPLICATION FOR PERMIT • :,SAN.w,:J'OAQUIN-.COUNTY PUBLIC HEALTH�SERV,ICES!. r-.,�-,, ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I§SUED � (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 tb City Lot Size/Acreage •a.-- --_.-__._-��% ?1 �� d _4.` Phone`"-. — Owner's Name -_ Address—-�„ s,.. Contractor_ � Addressi License No. Phone e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ # PUMP INSTALLATION ❑ SYSTEM REPAIR i 1 OTHER ❑ Monitoring Well E7 . : 4;; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL P175/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4.j n lAdustrlil ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public is Other n Delta Depth of Grout Seal Type of Grout I I l 6igation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P, State Work Done _ i Sealing Material & Depth Well Destruction ❑ Wet] Diameter I # j Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION •REPA+RdADDITION I I DESTRUCTION I I INo septic,system permitted it public sewer is i available within 200 feet.I Ins tallati h will serve: Residence-Commercial— Other Number 81 living units: _ Number of bedrooms _ # s�4 Character of soil to a depth of 3 feet: C-� b Water table depth ~ € /�[rte No.'Compartments e� SEPTIC TANK. ❑ Type/Mfg Capacity..._,_...,^, ` PKC°. TREATMENT PLT. ❑ I Method of Disposal - 1 t ' Distance to nearest: Well Foundation Property tLine - LEACHING LINE ❑ 'No. & Length of'knes- -� '�}Cdr ,^Total length/size FILTER BED ❑- 6istance to neatest: Well Foundation L�u Property Line /` r k SEEPAGE PITS 11 Depth �,/S�� Size:` - el � ldNumber �' t �` SUMPS i Distance to•nearest: Wel(' fr Foundation ' }i` -f PFoperty Line 7 -~ DISPOSAL PONDS ❑ �` s I I hereby certffy that I have,prepared this application and that tlework will be done in accordance with San Joaquin county ordinances, state laws, and �. rules and regulations of the San.Joaquin County..------- - permit Home owner-lf.licerlsed agent's•signature cenifies the followirfg: "1 certify"first in therformance of i6' work`Por which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 call for all required inspections. Complete drawing on reverse side. / Signed X ' Title: '_ i Date: ,� �� F !: ENTP l USE ONLY f { App cation Accepted by Date t Area Pit or Grout Ihspection by DataFinal Inspection b _ i Da + te/ i Additional Comments: I ' Applicant - Return all copies to: San Joaquin County Public1'Health Services, Environmental Health Permitl/Ser$ices l 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEK. 6 INFO AMOUNT DLtI AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO, . EN 13-21tREv.I RSY..._..., IN EH A-211 _ r