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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES J ENVIRONMENTAL HEALTH DIVISION , 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 REMLT _EXPIRES 1 YEAR FROM DATE MSMEM (Complete in Triplicate) r 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. A �1�{(j -bl So�3 S KI�tG51 Y �bj�p STO,MN Lot Size/Acreage Job Address City AMEA4#J AVI& Phone f�sC-1� i�J --TV: M_ Address_ T Owner's Name � � LrVC - y i I 3 UI �GT� C_Lfkx.� it's License No. S. l�- ?Phone . lb 631-q6 Contractor 4l l 4f+ Address LI TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION I❑ Out of Service Well PUMP INSTALLATION C3SYSTEM REPAIR ❑ OTHER ; Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,, DISPOSAL FLD. NA PROP. LINE ry a� -- — AGRICULTURE WELL OTHER WELL '^ PITS/SUMPS '� FOUNDATION �r INTENDED USES: �_TYPE-OF WELL PROBLEMAREA -CONSTRUCTION SPECIFICATIONS Dia. of Well Casin �...- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g N Domestic/Private ❑ Gravel Pack F7 Tracy Type of Casing Specifications I'1 Public 1-1 Other I. Delta Depth of Grout Sea[ f Type of Grout I I Ifiioation —..Approx. Depth ll Eastern Surface Seal Installed by f Repair Work Done U T pe.0f Pump I N.P. State Work Done I[ i g T Sealing Material & Depth TLICi %tr d T [ Qfic"E&Ctrl#uNkKH�- ❑ ameter r -- �S[fzQel 1 XPLOMP4XWw L- iS Depth �5 p{ ( Filler Material & Depth ` F 6,90V kPWANk �� TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I i DESTRUCTION I I Ilio septic system permitted if public sewer is available within 200 feet.) Installation will serve:� Residence Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:* Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ) 1 I LEACHING LINE C1 No. & Length of lines Total IengthJsize FILTER BED . Cf Distance to nearest. l Wel. Foundation Property Line I t SEEPAGE PITS 11 Depth - I Size s Number SUMPS LI Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ ' 1-hereby certify-that-l-have prepared this application and-that-the-work Will be donelri-accord"ahce with San Joaquin Conry 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 personsubject to workman's compensa- tion laws of California." The applicant must call for all uired inspections. Complete drawing on reverse side. f ( Signed X - Title: GI Pi &R- _Date. �! 1� 1 FO DEPARTMENT USE ONLY Application Accepted by ..4,'. -. Date / �U r` / Area �I �c"rr4lllCaic.s Al Data �Z A Pit or Grout Inspection by Date Final Inspection by fac. 4.a, Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i 1601 E. Hatselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. �IIN1Fn'O� 1Dr'!7] ��iC� Ii'ClAS/H . EH13.24(AEV.1rn5) 5 V E U��UG realI�4yJ- +� EH 14-26 F �.