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APPLICATION FOR PERMIT SAN J�QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 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 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 Service �� /////�� /n/ //� _ Job Address a�a �(/� N�,� /Il'L��C /U C/itty/(V Lot Size/Acreage Owner's Name / tr""u^'c'�tz-,�.VY� /Address 7 of 1,�/�7��),� -�• �1 I z Phone r ' 1 U ��( Jb CX1"d! Z Z2(o Pnone. b /o Conbac Address License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x� P. Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public ❑ Other fl Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Piller Material i Depth ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ CommercialOther Number of living units: —L- Number of d ooms_ Q Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK JQ(- Type/Mfg ,t IO Capacity No. Compartments PKG. TREATMENT PLT. Cl r / Method of Dispysal Distance to nearest: Well 5b Foundation_/0 Property Line .� LEACHING LINE > No. g Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _/0/ Property Line �- r � SEEPAGE PITS � Depth Size /M _n Number t'il SUMPS LI Distance to nearest: Well 12.E Foundation_/12 Property Line DISPOSAL PONDS ❑ I hereby canify 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 m ail for all uire inspections. Complete drawing on reverse�si/Qe Signed Title: V, Date: FOR DEPARTMENT USE ONLY / ` Application Accepted b71— Date '�C Area ! 2— C)PO <�— P or Grout Impaction by Inspection by e�Finel -qi"ate — Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health _ Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201FEY INFO AMOUNT DUE AMOUNT REMITTED {f., CAS*,, RECEIVED BY rDATE P[ER MI1T4',NO. H 1.24(REV.rra SI �' 1 } ` { �. — 1