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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 BOR 2009, STtOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 15SUED (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. Ar ,//yy � 1 �� City A /'rHSize/Acreage Job Address _-At Address i� 7 W f'r 1T 3 �`.' ��rqs, t ^ 77 ,6 Owner's Name Phone Contractor f-e L r— Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ._WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 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 CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public CZ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrivauon —.Approx. Depth I I Eastern Surface Seal Installed by. Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth UI Depth Filler Material & Depth UJ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is f/"' available within 200 feet.) Installation will ser ve: Residence Commercial_ Other Number of living units: ---L Number of bedrooms 17 w -- Character of soil to a depth of 3 feet: S �-A Iffy— L cf 2 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' a LEACHING LINE ❑ No. & Length of lines Tatal length/size t ._._ .._ y ! � FILTER BEDJ!,o"bistance-to nearest: Well Found tion is v _ _ PT erty Line ff t ,. / Z e ck SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ .1 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 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 lawa I lornia," The appii ant rt call for all required ins coons. Complete drawing on reverse side. Signed Title: Date: F DEPA ENT USE ONLY Application Accepted byDate ea Pit or Grout Inspection by Date Final Inspection by Date k 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 DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'IVO. INFO i &t + 15 13-24(REV.r/Hal `72 EH 94.25