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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PEUIT EXPIRES 1 YEAR FROM DATE ISSUBP (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. gf AC, 32aX !Z9 Z Job'Address' • , t/v2, q 40 TU 1-Z- 2 D City r-01 l Lot Size/Acreage Owner's Name B®dQ 'PAII/ASe�J a.Address. e�1 �� Phone �sr'397 l� 'Contractor - L4p y J5-: Wool --- Address--7. A).. AZ? �l3�Pr _Af 4 '7 _License No.!f�Y 7L_-Phone � �.- TYP WELL/PUMP: _ NEW WELL ❑ �6_ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ELATION_❑ ----SYSTEM REPAIR 0 OTHER Cl Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK BEES DISPOSAL FLD. PROP, LINE FOUNDATION 4GR1CkltiTUREW OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC fVSa 0 Industrial ❑ Open Bottom ElManteca.- `_- Dia.-of Well Excavation �id=o�Weli Casing ' U Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing Specilicatl.r. 1'1 Public v- -� C7 Other _ f� Delta Depth of Grout Seal Type of Grout I I Irrigation Approz/Depth I-I,Easlern _ Surface Seal installed by Repair Work Done ❑ Type of Pump_ H.P. "' State Work Done _ c V Sealing Material 6 Depth F Well Destruction ❑ Well Diameter s Depth f" �, Filler Material Depth TYPE OF SEPTIC WORK: NEW-INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) t F ' "07� Installation will serve: . Residence_Z Commercial 7Commercial_ Other i /zEdaoe 1> 9 7 7-- Number of living unfits: L Number of bedrooms 6 i Character of soil to a depth of 3 feet: ' A P-D PA AJ r Water table depth „ SEPTIC TANK. 0" Type/Mfg c c P L- Capacity /!a4 0 No. Compartments 1 PKG.,Tf1EATMENT PLT, Gl\ Method of Disposal r �F7 Distance to nearest: Well S-0 foundation Properly"Line ` ' Total len th/size LEACHING-LINE -,-�No. & Length of lines � 9 FILTER BED ❑ Distance to nearest: Well /SZ5 f" Foundation /S7 Property Line 3 SEEPAGE PITS I Depth _ ,a,1=r Size SLP rr Number SUMPS LI Distance4o nearest: Well f-'5'6'1- Foundation '¢� Property Line 3d r { t . � DISPOSAL PONDS ❑ ' I hereby certify that l 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, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 taws of California." `` ` The applicant must call for all required inspections. Complete drawing on reverse side. } C f.Gt Signed x �.. � •Title: Date: T � OR DEPARTMENNT" USE ONLY 4 Application Accepted by r Date ' f r Grout Inspection by� t]at -- ---�= Final Inspection by Date r i 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 AMOUNT DUE AMOUNT REMITTED CK R RECEIVED BY GATE PERMITNO. i INFO h ��►{{�� / ` + EH 13.21 IREV.r t n 5l EH:1.26