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APPLICATION FOR PERMIT j L)I- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DAIN 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I Pi$yse" Lh4c '-X0'ZoGe&S ZA' city Lot Size/Acreage C-A+IV-!n I �. 1 W � Address ,'�3 1 55kttx c� . Phone a-6 Owner's Name � - - "Prrc•� tl10 ?:zti��..1.,�0 art( 0 ",. of� wwrr� - CtYott' L !Ue r Lo tg�°�� 1'ttLl I Contractor Address 's A`L� C-41%1 I( License No.t Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well (3S %%- Ibpares DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. ROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION // E� Industrial D Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic]Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public [:1 Other f1 Delta Depth of Grout Seal Type of Grout.. M ew (� i I Irrigation �.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number SUMPS L3 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Z, 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 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-0 tion laws of California." The applicant mu c I for all r q ired inspections. Complete drawing on reverse side. / Signed Title: LCL+ ^t lrL�_ Date: , t i 9 4 II I FOR EPARTMENT USE ONLY Application Accepted by I UZI, Date O Area_ J Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEi )NFO AMOUNT DUCE AMOUNT REMITTED CASA RECEIVED BY DATE �PERMIT'NO. l + EH 13-24(REV.1/N til Q 10-1 137 I EH,4.26 {t�� go J 7 9 f I