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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, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in 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 Services. Job Address //g00 G /LET7"1_.A�_ /LAA✓ /�'J City J-0-VI Lot Size/ reage 2.cp, 7z Owner's Name ILIA) 0`//4/40 Address Sf7"c' Phone Contractor FLO YD kldnD Address -7d/ AZ).-4- .GTA icense No, s<7�SY7� Phone7J TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll 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 M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 1.1 Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done L] Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sower is / available within 200 feet.) QZ Installation will some: Residence ✓ Commercial_ Other Number of living units: _/__ Number of bedrooms 3 11 Character of soil to a depth of 3 feet: S A s/D 46G, rs4 Water table depth SEPTIC TANK D Type/Mfg P96-L Capacity 1 Z-O zp No. Compartments �-- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well fl Foundation -So r Property Line .w M 1 LEACHING LINE No. 6 Length of lines 3 —�O r Total length/size /7,0/ FILTER BED ❑ Distance to nearest: Well Foundation 3.n Property Line _!�-r9 r SEEPAGE PITS I Depth / Size Number 3 SUMPS LI Distance to nearest: Well +'' Foundation J�00! Property Line �� r 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: "1 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Data: -7 FDR DEPARTMENT USE ONLY (� Appl' ation Accepted b/ Date�_/ / ��2 Area a—/ y°—�/2 �QateQ� Pit r Grout Impaction by at Final Inspection by �— Additional Comments: 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 aE! OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER M17N0. _ / ,/ qq '//� . EN U-]4IeEV.vnm `�/ 114''9J �7y7 r {FN J.M -