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�( APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 f:f , P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED (Complete is Triplicate) Application is-hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance`vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �n , Qsir n. /�G/ . o Lot Size/Acre eJob AddreS City � F Owner's Name r ' Address 294/ Phone- Address _ - Contractor_ ��' Address License No✓O� 7"�I Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER 1) Monitoring Well C7 CDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION_ AGRICULTURE WELL OTHE=R WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL, 3 PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� industrial ❑ Open Bottom C ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [:I Domestic/Private �k'❑ Gravel Pack ❑ Tracy Type of Casing Specifications - I'l Public (-7 Other ` ' n Delta Depth of Grout Seal Type of Grout I I Irrigation ____.Approx. Depth I 1 Eastern Surface Seal Installed by � Repair Work Done ❑ 'Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth �C Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is a/ available within 200 feet.I tnstalfation-wil!-serve:—Residence-_` Commercial_other +� Number of living units: _ ,!Number of bodroofns _'¢ aZ 3 Character of sail to a depth of 3 feet: r _ T � _Water table depth Jr4o ' SEP'TIC.TANK. O Type/Mfg Eli I Z/ !" Capaciiy //�nr No. Compartments 2- c:--l ! PKG. TREATMENT PLT. { � �/'.�� r,r � Method of Disposal . Distance to nearest: We* 1 Foundation }j�t �Property Line f LEACHING LINE LSI' No. & Length of lines 21Total length`�'sire 1'::E - Q0 FILTER BED ❑ Distance to nearest-7 0610.d6i.n Q Property.-Line S' SEEPAGE PITS NI Depth Size f ' ( _ Number SUMPS LI Distance to nearest: Well j t Foundation ' Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dome inCco(dance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i } 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this,pe"rmit is issued, I shall employ pe sons subject to workman's compensa- tion laws of,Califorpla." } h 1) The'applic If tali for all re iced ' spections. Complete drawing on rre [e side. Signed, ! Date: 7,�'�/ `' R DEPART ENT USE ONLY ,.. Application Accepted by Date- l Area Pit r Grout Inspection by Date final Inspection by Additional Comments: Applicant - Return 9.11 copies to: San Joaquin County Public Health Alw Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO FEE AMOUNT DUE j AMOUNT REMITTED f CASH CK I RECEIVED BY DATE PERMIT NO. CH 13 24• BI-261REV.tw is l � 1 EH � �.� t! � � �' ��` •�