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APPLICATION FOR PERMIT SAI. JOAQUIN COUNTY PUBLIC HEALTH -riRVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 - P 0 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 application.i&made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Healt Sery ce 7ZO Job Address c5OcJ%tl^'� /9r r �i �_ /��/L�1��1� City X12 �� Lot Size/Acreage 700 .S T Jji0540-r S7. IO vE� _ Owner's Name )J - 'rV �/f /;EL!ai ��jAddress S G �� S /n Phone\q/} ) �VLJT i l7�4�vt+;a 3: -, 41TLc=�r_w,� r �r�c�H7 Co:Dcx�R 5�'.ic f 7 116 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DES ' 0Ci NC1Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHE PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC CJ /, El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat /oDia. of Well Casing / [1 Domestic/Private ,Gravel Pack ❑ Tracy Type of Casing_Z-1,= !/L Specifications (h I'I Public II Other F1 Delta Depth of Grout Seal S 30 Type of Grout I I irogdoon —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done a Type of Pump _ H.P. State Work Done _ Well Destruction ❑ Well Diameter 1 / Sealing Material i Depth Depth �' ZC1 x1-S / Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other A Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: l t_ T "t' CL-;Ail 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. & Length of lines AJQ Total length/size FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation 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 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 no 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 appli Xcan ust call for all required inspections. Complete drawing on reverse side. l Signed X Title: ) W L Cl_01>��i-1? Date: � U / / N / EP ENT USE ONLY 7 r Application Accepted by Date ` �j res3 -z_Si �� Pit or Grout Inspection by Dat Final Inspection by Date , r Additional Comments: r' vJ Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 2601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201FEE ' IN AMOUNT DUE AMOUNT REMITTED rASN RECEIVED 9Y DATE PERMIT N0. EH 13-41(REV I -DL-1( d7 t, - ` -- � -