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APPLICATION FOR PERMIT SAN 'fOAQUIN COUNTY PUBLIC HEALTH SMVICES 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 is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 0 application 1e made 1n compllmce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ( „ Joaquin County /Public Health Services. f %�,/'' s7 W Job Address ^� ,��C� r-T� � /� ` ;rc City��N Lot Size/Acreage i/�- O Owner's Name .�1-�/�!z/"Ff' �lL� AdC �n .� �z Phone n � �T-��/ /� tea-, _- _ Contractor LTH �125 �" Lef/. Adtlressl�1� ��///L-,�� 2sNoPhon 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 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public 1-.1 Other Il Delta Depth of Grout Seal Type of Grout — 1 1 IrHpution _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 Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is ��,�'�` available 4within .200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Ja(,4 Number of bedrooms_P444_ � Character of and to a depth of 3 feet: �'� Water table depth SEPTIC TANK )9 ��_�1r� ` Type/Mfg 004"W Capacity LNo. Compartments PKG. TREATMENT PLT. ❑ _ z c/ Method of Disposal IPj Distance to nearest: Well Foundation Property Line LEACHING LINE P(1 No. 8 Length of lines �27 'SZ-7' Tpl length/size FILTER BED ❑ Distance to nearest Welt_A1C3bZFoundation / Property Line SEEPAGE PITS )S,-Depth fJ !:57 Size rr 610ber SUMPS LI Distance to nearest: WellFoundation Property Line DISPOSAL PONDS ❑ I hereby cenity 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 sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requir ins ctions. Co late drawing on reverse side. ` T Si ed X -�- 6 ac'"z� Title:C��2_"_- Date: �� ^o R DEPARTMENT USE ONLY o Application Accepted by l�l�r'`� ' Data ` Area l Pit or Grout Inspection by Data Final Inspection by Date 17 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Enviroomental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT D�U/E� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. • EHi3-24IREV.1/xslINFO , . . OI� M\R EN:42a cew � l v 1