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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY Pi]BLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , .PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PENIT 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Countblic_HealthFServices. Job Address f�l---V "' �fl f`'�0i n- r C;ty �� P t- CC� Lot Size/Acreage \` Owner's Name ddress f= C % �.��t k_, (�f�f k� '94)7'-APho,e ' Contractor CIX0 F- �ri °Address h d \ Z License No. Phone 'r YPE OF WELL/PUMP: NEW--W E L L7 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl R , PUMPIN8Ti4CLAT10�� SYSTEM REPAIR ❑ OTHER ❑ onitaring Well L� 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 I Cl Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing A y Type of Casing Specifications /7ff.QDomestic/PrivateGravel Pack ❑ 7rac T I'I Public CI Other fl Delta Depth of Grout Seal �f)Q Type of Grout I hanon ri E1' 1!:!a.Approx, Depth I 1 Eastern Surface Sent lnsiailed by < l� Repair Work Done 0 Type of Pump 6o b, H P. � State Work Done v Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAI /ADDITION l I D TRUCTION I I (No septic system perniified';iIJI51U IZ-sew, is available within 200-feet'. ac's Installation will serve: Residence____ Commercial_ Oth r Number of living units: Number of bedrooms 010 Character of soil to a depth of 3 feet: / Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well \Fundation Property Line LEACHJNG LINE CI No. & Length of lines Total length/size -� FILTER BED ❑ Distance to nearest: �We[I Found tion Property Line � ' n SEEPAGE PITS IJ Depth Size Number SUMPS Ll 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 with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature-lanifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no 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. �a ' Y Signed Title: . 71.Lh1 _- Date: °s 9� DEPARTMENT USE ONLY Application Accepted by Date Area PitoDro Inspection by '� Date Final inspection b Date --� Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Fermit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 lFEEO AMOUNT DUE AMOUNT REMITTED CA$H RECEIVED BY DATE PERMIT'NO. . EH t3.24MEV.r/n%) 1 & EM -.4-26.�, 3 ,oto 0 v '� 7�a-