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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 0 BOR 2009, STOCKTON, CA 95201 PERRMIT 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 fHealth Se"ices. Job Address r.2/6�.�-f}7--`9E7��/JI •,r � 1'�� /C��c^ City ( _ Wt Size/Acreage Owner's Name ,//�ZAI C. n�HHdt.�/ Adddrresss .� -) t971� Phone Contractor J✓tt, Address f a License N090T74/ Phone 3y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR CI OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C/ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - s' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /- fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications y 1'1 Public O Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Material L Depth -- TYPE OF SEPTIC WORK: NEW INSTALLATION ILK REPAIR/ADDITION : I DESTRUCTION I I (No septic system permitted if public sewer is J available within 200 feet.) ' Installation will serve: Residence � Commercial_ Other Number of living units: Number of bye ooms Character of wN m e depth of 3 feet: Water table depth L� SEPTIC TANK 0— Type/Mfg .vim- _ ... sf e—_ Capacity— //, — No. Compartments , PKG. TREATMENT PLT. ❑ F Method of Disposal ��/,r� Distance to nearest: Well � Foundation //01 Property Line 2S- LEACHING LINE {eY No. 8 Length of lines �� ytTlot�al length/size /10 FILTER BED ❑ Distance to nearest: Well Foundation � Property Line f SEEPAGE PITS 14/Depth �5 r Sizejo�I rr Number SUMPS LI Distance to nearest: Well LL Foundation Property Lina 160 r DISPOSAL PONDS O 1 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 cenifies 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 applic nt�must call for all req ued inspections. Complete drawing on reverse side. 77- Signed X�!!dA s Title: 4J(�ln1C( Date: / 7 C/'U FOR ARTMENT USE ONLY anon Accepted by �y�� v.CL J �-�� Date �-/ �J- / cl Area .� Pit or Grout Inspection by 11111� Date 7 L� Final Inspection by ��, Date /i 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CABI, RECEIVED BV DATE PERMIT NO. L• ER 13.111REV.11xe1 ,00 . U p 3i7o u `r EH A.Sa I / l /-J ��I Ur 1U - l7E� 1