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APPLICATION FOR PERMIT .r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 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 " 1862 and the Rules and Regulations of San A//Joaquin County Public Health Services. C1 I� Jb Address 1341S N. !1*0t tOnrC QC�>' City Lcl Lot Size/Acreage I \j�Owner's Name itvrsr- O:\ C. Address S&JAAe t�r�g�. Phone S�zyaO Contractor 1Zc335 Eh2Tt1 AaptaMi Address 3>0•Viw TSS l0c][pyt \ License No. `tiS9096 Phone NA-7S70 YPE 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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public n 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 i Depth c`` Depth Filler Material i Depth •'11 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONo septic system permitted if public sewer is \ available within 200 feet.) ..� Installation will serve: Residence_ Commercial_ Other („ Number of living units: _ Number of bedrooms V Character of soil to a depth of 3 feet: Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments `V�1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 subcontracting 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." I' -0-4x1The applicant must call for all required inspections. Complete drawing on reverse side. �/Signed1( _64 Title: -013ZRI�CToyi Date: I gUNif91 '\ F&R DEPARTMENT USE ONLY I ^/ Application Accepted by QO G`__ ,A L A Date Area / Pit or Grout Inspection by Date Final Inspection by Date7 Additional Comments: L 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 NFE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ♦ GATE PERMIT'NO. . ENI]-]x 1aEV.r/nsr166 1 ai � 7 r O� ? y SEH U-