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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, STOC%TON, CA 95201 /32 06o Ga PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 2S/' Application Sa hereby made.to San Joaquin County for a ie permit to construct and/or install the work herein described. application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Country,jPublic Health Services. �7 e Job Address �/�'1-�rblC'�// clL- In QJ.� 1�-•� City 15't Lot Size/Acreage .2 L,L6V6 S Owner's Name t!'GaYLL, r5.F,C .Ll f Ile Address _ e,--Yylgf _ Phone p��y� RJMr c SEK c.• /) `-'/33a S e? I- Contractor`--" �� Atloress �U � � f License No. phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION;❑.Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD:.-� PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL ' SPITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications,.—,— I'1 Public Ll Other ll Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. .1 State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth f Depth Filler Material b Depth -� C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No _ septic sstem permitted i(public sewer is available within 200_teat.) Installation will sane: Residence_ Commercial-4 Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water tabb`'depth -' SEPTIC TANK. ❑ Type/Mfg Capacity r No. Compartments EKG. TREATMENT PLT, ❑ /yk6 2-y 1 CUyvl�a.�Me.^� LZ I [, a�- Method oi_OisQosal - C Distance to nearest: Well Foundation Y, Property Line - C t LEACHING LINE ❑ No. 6 Length of lines Tata( length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f - t SEEPAGE PITS 11 Depth SuNumber, r 'r SUMPS 0 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 i with rules and regulations of the San Joaquin County San Joaquin county ordinances, state laws, and , Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for I dwhich 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 of sub'contracting signature certifies the following:"1 certify that in the performance of the work for which this permit is ixuad, I shall employ persons subject tc warkman's compensa., tion laws of California." The applicant must call for all req d SPactlO s. Complet drawing on reverse side. , Signed Title: �-t_ Date: _ FQR DEPARTMENT USE ONLY C Application Accepted by Date � � Area Pit or Grout Inspection by Date Final Inspection by S Data GZ� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO /yCAnSH DATE PERMIT NO. . EX 1Yt11REV.rens) //�' f ,],{ - C'r'1 f / / / a 6- � ,_ _ '