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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 O BOX 2009, STOCKTON, CA 95201 RERMIT EXPIRES_ 1 YEAR FROM DATE 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address A)3 3 Y - Sc U T T-5, a �/€ ; _ City Lot Size/Acreage Owner's Name G:�-A R Address 3 3 �a TS Phone 3616-7 0frtt Contractor $fF ARLt 41 /L CO< Address 1 -',Yo (i Aotk License No. S/9�.'tEs Phone TYPE OF WELL/PUMP: NEW WELL (fir WELL REPLACEMENT 0 DESTRUCTION ❑ Dut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation __ 7 Dia. of Well Casing Cl Domestic/Private C"Gravel Pack ❑ Tracy Type of Casing v Specifications �• I'I Public is T Other n Delta Depth of Grout Seal S /g P � Type of Grout 6 I I Irrioation S `Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done 0 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 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is Installation will serve: Residence__W_. Commercial— Other available within 200 feet.l Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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." The applicantmust call for all required inspections. Complete drawing on reverse side. 11;Signed Title: 4/.,-s .S Date: L�, _�,,[,( FOR DEPARTMENT USE ONLY �/l � t/ Application Accepted by �t L`^ Date 7 1 q/ Area p,"-r 7 q Pit or Grout Inspection by _ Date /' Final Inspection byDate/4 ` � r 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 INFO AMOUNT DUE AMOUNT R�EM�ITTED CASH �RECEIVED BY i DATE n i PERMIT'NO. a EH 13.74 IREV. /r 5) �j��O EH;475 Q