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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address�L 7 3� +r"+�+�''�� 9-k city ' Lot Size/Acreage 7 Owner's Name %`"�� ""� Z'` '` -- _— Address 117-3 Phone Contractor r!',z z l—Address�G" �'� License NA-41 ?-3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK: a SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. } AGRICULTURE WELL ____L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIE{CATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia: of Well Excavation Dia. of Well Casing HT Domestic/Private 0 Gravel Pack n Tracy Type of Casing Specifications 1'1 Public l-1 Other I l Delta Depth of Grout Seal Type of Grout I } Irrigation Approx. Dept I I Eastern Su ace Seal Installed by , Repair Work Done L� Type of Pump �'� H.P. / State WorVDone J� -- -- �• Well Destruction ❑ Well Diameter j Sealing Material & Depth t� } Depth ; Filler Mate'iial & Depth) i 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I-I DESTRUCTION I 11INo septic system permitted if public sewer is available within 200 feet.) installation will serve: `Residence— Commercial_' Other t Number of living units: Number of bedrooms I�II � I Character of soil to a depth of 3 feet: 11 Water table depth SEPTIC TANK. 0 Type/Mfg .. Capacity No. Compartments PKG. TREATMENT PLT. 0r r;� _ _ . - a Method of Disposal, Distance to nearest: Well Fbundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size tu. FILTER BED ❑ Distance to nearest: �Well Foundation Property Line i SEEPAGE PITS l I Depth =Sire Number i SUMPS U Distance to nearest: 'Welt Foundation. Property Line DISPOSAL PONOS ❑ . I hereby certify that I have prepared this application antl 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 sha{I 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." 1I The applicant m st call for all req�uir Sd inspectio Complete drawing on r rse side. F Signed X__ [� �'4 �'L�?�. I itle: t'�'1� Date: L_ f R DEPARTM T USE ONLY r Application Accepted by - - Date Area Pit or Grout inspection by Date Final inspection�b�b� � Additional Comments: Applicant - Return all copies to, San Joaquin County Public Health rServicea, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT NO, . EH 17.26 IREV.1/r+sl EH 44-26