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APPLICATION FOR PERMIT SIS! SAN JOAQUIN COUNTY`,PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA V5201 i . i ]EXPIRES 1 'YEAR FROM.D ED �. (Complete is Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This t application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health.Services. K . t Job Address CityLW1h9p Lot Size/Acreage 1. Owner's Name Address � � Phone '770r f�Z r Contractor_eej:LAddress X74 License N1_V_2_Uf_Phone 33V- W ' `— TYPE OF WELL/PUMP NEW WELL-.% REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 PUMP INSTALLATION SYS S M�REPAIR Q OTHER ❑ Monitoring Well L� 1 �r I 4 DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE _ # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial El Open Bottom EI Manteca Dia. of Well Excavation_ .._� Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of CasSpecifications I'I Public I-1 Other j.. 171 Delta Depth of Grout Seal* Type of Grout I f i-I Irti0ation --O-.Approx. Depth-"11 i Eastern Surface Seal Installed by `Repair Work Done ❑• .Type of Pump � � \_H.P. State Work DoneWell Destruction ❑ Well Diameter- + Sealing Material&De`pth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I. DESTRUCTION i I INo septic system permitted if public sewer is i available within 20G'feet.i j Installation wilt serve:. Residence '''"'Commer is as_ Other t -� ``Number of�living units: Number of bedrooms � } F N. Character of soil'to a depth of 3 feet: Water table depth _ •.SEP-TIC TANK. / O'--Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ + `� Method of Disposal - Distance to nearest: Well Foundation _ __ Property Line 4 LEACHING LINE L1'` Na. & Lc ng`th o.lines Total length/size j FILTER BED Cl Distance to nearest; Well Foundation Property Line7. -. ►_ + - i SEEPAGE PITS I I Depth Size Number SUMPS L! Distance to nearestWell Foundation Property rtYLine 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 a 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 campensa tion laws of California." ' The applicant must call for all req�u./ed 'inspections. Complete drawing on reverse side. p Signed X ��t _ L - - - Title: Date: FOR DEPARTMENT USE ONLY ^t Application Accepted by _ Date L Area ! / Pit ar G ut Inspection by Dae ��` '� Final Inspection by , Q h�I� Data 2 `Ll Additional Comments: — r Applicant - Return all copies to: San Joaquin County.-Public Health _ t Services, 1�2vironmental Health Permit/Services # 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201'`. FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO l� CASH . EH 13-24 tREV.J/n 51 13 •.ate 13111-7/)'0 �q q 2�~-176 7 EH it-26 r CfJ +�q�4