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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 BOX 2009, STOCKTON, CA '95201 PMIT 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ` Job Address 11,41/3 f /l L c7�99� City ( Lot Size/Acreage /V hL, 4Ow " ddress 7A e Phone I Contractor � Address License No. Phone TYPE OF L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION MOut of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑% Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK LQfr SEWER LINES DISPOSAL FLD.LQ��1��y�PROP. LINE W� FOUNDATION AGRICULTURE WELL OTHER WELL�LZ PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREN' •CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom O Manteca , Dia. of Well Excavation Dia. of Well Casing D Domestic I Private Cl Gravel Pack El Tracy Type of Casing Specifications I') Public [:1 Other Fl Delta Depth at'Gro t Seal � Type of Grout 11 hrigation �.Approx, Depth �t I Eastern Surface Seal Installed by f Repair Work Done .L7 Type of PumpH.P. State Work Done r /� a Well Destruction Well Diameter 6'/ Sealing Material & Depth Depth Filler Materiel & Depth ,, xr _ TYPE OF SEPTIC WORK: NEW IN LLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T Commercial_ Other " Number of living units: Number`tif bedrooms T ' 4 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type,/Mfg Capacity No. Compartments • PKGyTREATMENT PLT. ❑ Method of Disposal Distance to'nearest: Well Foundation Property Line r o LEACHING LINE 0 No. & Length of lines C� r ' Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line J SEEPAGE PITS 11 Depth Size _ Number w SUMPS Ll Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS 1:7 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: "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 appiicpnt must c a21, ired inspe, o I' t raw n reverse side. Signed itis: Date: FOR DEPARTMENT USE ONLY Application Accepted �-�+ _ Date _ Area Pit or Grout Inspection by Date Final Inspection by s Date r Additional Comments:"' Applicant--Rett ti till copies to: Sen Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 fFEE � INFO AMOUNT DUE s AMOUNT REMITTED ASH r RECEIVED BY �� DATE TPERMIT N0. • EN -24 IAEv.I�rsr �j i D /G / / ( /9 -9,0�/3�� /v EH A;i2a V .L b