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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 BOR 2009, STOC%TON, 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 coslpllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. h/{,,,,� ,y/{,- Job Address 4-3/ © c)6 • / / f City Alf" Lot Sit /Acreage Owner's NameAddress �Q ljooC 91s' LJIW7, OfA phone Contractor _Address OW Y16 License No. Phone .�— m TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl 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 PROS CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. o cavation Dia. of Well Casing F I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ~' 1'I Public 1-1 Other 1`1 Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by G Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted it public sawer is available within 200 feet.) Installation will serve: Residence g Commercial_ Other Number of living units: f Number of bedrooms 2_ Character of soil to a depth of 3 feet: "c- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. 8 length of lines Total length/size- FILTER BED CI Distance to nearest: Well Foundation ,Property Line SEEPAGE PITS p( Depth r0— Size. 77—_ Number / SUMPS LI Distance to nearest: Well fQd Foundation ,'kj r 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 Country 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." The applicantm t call for all required pec ns. Complete drawing on reverse side. c3 Signed X Title: -SE Date: FOR DEPARTMENT USE ONLY C_ Application Accepted by //�� Y,�L., _Date `"� -�� Area 5 Pit or Grout Inspection by Date Final Inspection by Date 7o Additional Comments: Applicant - Return all copies tot San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EMI]NIRV.ir.st EN A-2111 � � a9