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I I � APPLICATION FOR PERMIT "' 1. i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , I,'.PHONE (209)468-3420 H P 0 BOX 2009, STOCKTON, CA 95201 M >Z-6 No,11 Zyc Z j1 tf - PMWIT EXPIRES 1 YEAR FR M DAT PD omglete is Triplicate) ' Application is hereby made;to San Joaquin County for a permit to construct iand/or install the work herein described. This t application is made in compliance with San Joaquin County Ordinance No. 549 and�862 and the Rules and Regulations of San t) Joaquin County Public Health Services. i"ryl-6 S AA? OWx' '0.3 -- Ej�-w] ¢-J g �!� fig7 oftf Lot Size/Acreage Job Address J�u� Owner's Name LQf L!'ngn!A __ . Addressr!Zp % �S �J Phone M r Contract r' ddress 2-5_ IF-r E ST License No.,Z7-6 -Phone 9 g— 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ e ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES IM DISPOSAL FLD. FOUNDATION AGRICULTURE WELL OTHER WELL' - nCD11 E _ -- 44 G I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G EI Domestic/Private ❑ Gravel Pack L7 Tracy - Type of 4Casing Il Public 1-1 Other Cl Delta Depth of Grout Seal S 1 I I Irrigation _Approx. Depth I I Eastern Surface ISedl Installed by Repair Work Done ❑ Type of Pump H.P. IM State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADDtTION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) `C 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. ❑ Type/Mfg Capacity No. Compartments ?` PKG. TREATMENT PLT. ❑ 1 Method of Disposal � Distance to nearest: Well Foun Nation Property Line 41 LEACHING LINE ❑ No. & Length of lines 'M Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line II SEEPAGE PITS I I Depth Size Number .s SUMPS LI Distance to nearest: Well Foundation Property Line s DISPOSAL PONDS ❑ l� I hereby certify 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 oenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not I 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." `) i I The applicant st call for all ed inspections. Complete drawing on reverse side. C Signed X-= '` Sj - — Title: 6 Date: — I FO DEBARTMENT USE ONLY I Application Accepted by Date `� — d Area s Pit or Grout Inspection by Date Final Inspection by Date v / r r Additional Comments: ` I Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 .i I MOUNT DUE AMOUNT REMITTED CASHCK ) RECEIVED BY /DATE PERMIT•NO. a EH 13-24 IREv.t/n 51 �� O/ j� Q-)1, EH 14.26 r