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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 BOR 2009, STOCKTON, CA 95201 SCANNFP PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or Snatall 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. Job Address 3 y-2-5 1,4143 l.J/Y/c.b 4 City `j Y'A'AJ Lot Size/Acreage 14W �ZU Owner's Name DAa'ID i3011JA )LI"A Address Ste+-mE Phone 9.31-17S- Contractor .3 —Contractor g, Wdal Address Z Al, AtiW License No. � a ( Phone 4-&S--33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RICULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A A C STRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — L1 Public 1-1 Other fl Della th of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I E am Su a Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Materia d Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I D7"7- to �aptir s.� med if public sewer is available within 200 feet. Installation will serve: Residence Commercial_ Other FEXIST/AI /3 Number of living units: —L Number of bedrooms P,f low 7-v .�- Character of soil to a depth of 3 feet: G6-AX a epth SEPTIC TANK ER'Type/Mfg _Ce- Pei-L Capacity .2= 00 No. Compartments PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well -7a Foundation_12' Property Line 40' LEACHING LINE No. 6 Length of lines 3 —(nc7 Total length/size l60 FILTER BED ❑ Distance to nearest: Well /11,< Foundation /O/d 1 Property Line .- SEEPAGE PITS iW Depth 2,� ' Size 4-.:)L- Number .3 SUMPS LI Distance to nearest: Well Foundation ZOO Property Line S DISPOSAL PONDS ❑ I hereby certify that I 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, 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all required�inspections. Complete drawing on reverse side. Signed X ,.-s�� G�h-r'clC Title: Date: 7-/9-`)O EPARTMENT-USE ONLY fJ 9 Application Accepted by w. �Y�J.� Date �' v ` -0 Are Z Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO j /pASN,1`' . ER 1124(REV.1195) EN 14.25 1 1 v t 1 Lii U 6 VO'