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+ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION z' 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 o v 55 Z We'�[ P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES„1 YEAR 'FROM DATE ISSUED t (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 SCJ 1 l C�� +ve, City S4XHOYI Lot Size/Acreage Owner's Name CIAddress �5' �—'� Phone ZL9 t ' F-0-h-ori1- � 1Z GContractor -� i Address ` . Ng2"ILicense NcC,"— 51k9CPhone O7d i TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION CI Out of Service Ne11 ❑ i' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Wel DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r r !t• FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l 3S r,EY9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14 Dia. of Well Casing 2 r1 El Domestic/Private [,Gravel Pack 17 Tracy Type of Casing V Specifications --�— 1'I Public Cl Other n Delta Depth of Grout Seal 3 Type of Grout I I Irrigation —.Approx. Depth I k Eastern Surface Seal Installed by Y�tr. Repair Work Done 0 Type of Pump H.P, tate Work Done r Well Destruction ❑ Well Diameter Sealing Material & Depth Q33 f� Depth r� � } Filler Material & Depth PK(!- Lon,(?5- jG r Sr-g f'33 \Sy TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i INC septic system permitted if public sewer is available within 200 feet.I J Installation will serve: Residence_ Commercial— Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method'of Disposal �r Distance to nearest: Well Foundation Property Line + LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lin 1O, I SEEPAGE PITS 11 Depth Sire Number `r _,�PC� SUMPS L) Distance to nearest: Well Foundation Property Li C• i f � DISPOSAL PONDS ❑ I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and I 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 of subcontracting 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 ust call for It required inspections. Complete drawing on reverse side. Signed X Title: ��rc.--- �Tc��o sJ� Dale: FOR DEPARTMENT USE ONLY Application Accepted by Date I Area Pit or Grout Inspection 4 i Pe Y Date Final Inspection by Date I Additional Comments: I 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 RECEIVED BY DATE PERM17'NO, INFO CASH //�� 4 + EHR-241AEY.irHss +0 )r►'1��fH i4.2e lJ IIk669 !-t `J1 °Illl (ECJ C