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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, 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 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 .199 2 2— E. dAe.4 A)GEE A&/E City Lot Size/Acreage AR, Ax_Q2 _ Owner's Name MARCO p Z/-S'-Z Address 3�* __— Phone g,Aw 3 ConLractor_FLjQ_y,& lOOdD Address 7 Ali ADELdE.eT License No, i�ZSL7L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Nell ❑ 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1`1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I'I Public L1 Other F1 Delta Depth of Grout Seal Type of Grout r. 11 Iniltation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth I Depth Filler Material i Depth \.. `\ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence✓ Commercial_ Other Number of living units: Number of bedrooms Z— I Character of soil to a depth of 3 feet: Std kib y C L.4ry/ Water table depth SEPTIC TANK ❑ Type/Mfg P4-L Capacity 1 200 No. Compartments 2— PKG. PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well /dD , Foundation �_ Property Line /B LEACHING LINE No. 6 Length of lines 00 Total length/size Z Oe FILTER BED CI Distance to nearest: Well 1019 t Foundation �!J ' Property Line _ t 1 SEEPAGE PITS I Depth ��r Size ~ _ Number { SUMPS LI Distance to nearest: Well /s0 • Foundation /911 rt Property Line 7 DISPOSAL PONDS O 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 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 applicant must call for all required insPections. Complete drawing onreverseside. Signed X � Title: C.i/W14L Date: 7—1 G- 4 2 FOR P T USE ONLY -� Application Accepted by Date c res 4:1�d::�y Pit or Grout Inspection by Date Final Inspection b Date/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Ratelton Ave., P 0 Box 2009, Stockton, CA 95201 IN FEE AMOUNT DUE AMOUN7 nEMITTED CK RECEIVED BY TE PERMIT'N0. ♦ EH 13 24 EH 1426 IREV.rin 5) L-`�J r '-`•� _ .r 1