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... _7� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL .HEALTH DIVISION y 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 XP RES 1 YEAR FROM DATE (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. 5149 and 1862 and the Rules and Regulations of San q Joaquin County Public Health Services. Job Address City�7`�irb�',t?.hJZV iJ Lot Size Acreage Owner's Name .IVA5TP#illA0 1 Address 51'fMr✓ Phone .2- J Contractor Fl-a ka (.�40ID Address `7 ill r A D,E L. License No. Phone TYPE Of WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑- DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing n DomesticiKr ate ❑ Gravel Pack ❑ Tracy��.. - 'Type of Casing Specifications I'1 Public Cl Other 11 ❑ Delta Depth of Grout Seal Type of Grout W I I Irrigation .Approx Depth € I Eastern Surface Seal Installed by Repair Work Done U Type ype of Pump _ H,P. State Work Done Well Destruction D' Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR lADDITION DESTRUCTION I I INo septic system permitted it public sewer is ` a available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: --t— Number of bedrooms—_ Character of soil to a depth of 3 feet:'_ to'D Y Ly7q,2,r, - __Water table depth —j SEPTIC TANK , l'Type/Mfg'. P 4�-4. Capacity__/Zer o No. Compartments }p PKG. TREATMENT PLT. 0 , Method of Disposal r Distance to nearest: Well �4 Foundation ._Z& Property Line .100 " LEACFIING LINE L< No. & Length of lines Z, g0 Total length/size 6 FILTER BED ' 0 Distance to nearest: Well Foundation `_ Property Line SEEPAGE PITS t! Depth Size Number SUMPS LI Distance t°I nearest: Well Foundation Property Line DISPOSAL PONDS p l - I hereby certify that I have prepared this'appl€cation 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 r' 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 persona subject to workman's compensa- tion laws of California." t The applicant must call for all required irispections. Complete drawing on reverse side. ' Signed X Title: Date: -2 7— FOR FOR DEPARTMENT USE ONLY Application Accepted by Date -7-2 Area 2 Pit or Grout Inspection by Date Final Inspection by Date Z.1 -T 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 INFO AMOUNT DOE fi AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH13-24IREV,E/H51 1 f �1 �� I y., a °�. - of 3� zz Z. EH t4•2e