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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATr_ ISSUED (Complete in Triplicate) Application is hereby trade 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/P�ubli�c HealthSer'vicI Lies. n ^�' rJ Job-Address ��/ -/ /• � �� ! _ City �0� L Lot Size/Acreage /9� Owner's Name � H, L AddressyrTIO'IE Ph,,,,,c3644tZ Contractor�k 7 Address��>��'! License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 'i7 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 CI Industrial ` ❑ Open Bottom ❑ Manteca I Dia. of'Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public f.l Other fl Delta f Depth of Grout Sealk Type of Grout } I i irrigation _.Approx.. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump """" H,P. } State Work Done, Well Destruction O Well Diameter Well Material & Depth Depth. , Filler Materiel & Depth y' TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION l I DESTRUCTION l I Wo septic system permitted if public sewer is avalpablle wwi�jC}n/�200 feet I YInstallation willserve: Residence Commercial _:.� •Other t _ 1 Number of living units: ' Number of bedroorns Character of soil to a depth of 3 feet:1Y 0 Water table depth �i SEPTIC TANK ❑ Type/Mfg Capacity7pD _ No. Compartments v Y PKG. TREATMENT PLT.❑ ' 1 I Method o Dispgsal Distance to nearest: t Well 7X Foundation 17 Property Line I�I LEACHING LINE i ❑ No. & Lerigth of lines Total length/sizeJAD FILTER BED Cl .}Distance to nearest. Well,.I�,�W ' Foundation� Property Line SEEPAGE PITS l 1 bapt h ' Size I` Number SUMPS Ll Distance to nearest: Well Foundation Property Line (- DISPOSAL PONDS ❑ t t I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances; state laws, and I rules and regulations of the San Joaquin County w 0.� 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 totbecome 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 The applicant m call r 11 requi a ins s. Complete drawing ori re rse side. Signed X Title: _ _ Date: 2 ql Y , { FOR DEPARTMENT USE ONLY Application Accepted by Date 7 �' Area ! 4 Pit or Grout Inspection by Date Final Inspection by Additional Comments: t t 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 REMITTED I CASH RECEIVED BY DATE /►PERMIMT'NO.r f EH 7{-EH 13-24 IREV.rin Si �1 W _lagp'[ P_ e w