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1' APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION t 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95203 PFJWIT 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County,Public Health Services. Job AddressIarl�t. ,R City Lot Size/Acreage Owner's Name _ �r;}lu 4C7—X1 ,,,rr��PC5'Y z Address �i1 `V CT Phone Contractor r ! !�-t_t� Address v, ZZ A5?9 License Nand?—Phone TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public is Other Fl Delta Depth of Grout Seal Type of Grout I l Irrigation —.Approx. Depth € 1 Eastern Surface Seal Installed by { Repair Work Done 0 Type of:Pump H,P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is I 5. , available within 200 feet.i E installation will serve: Residence.. Commercial— Other _ IE Number of living units: 4-L Number of bedrooms 4: ft Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK ❑ Type/MigL /�Crq__CrcT L Capacity.1l�-r� No. Compartments + PKG. TREATMENT PLT, C) r Method of Disposal ' Distance to nearest: Well _,10C,�ndation_ �T property Line �d � LEACHING LINE .❑ No. & Length of lines ram, rte. - oral length/size i FILTER BED 'El Distance to nearest: Well Foundation. Property Line SEEPAGE PITS ( I Depth Size _ _ Number i SUMPS LI Distance to nearest: Welf Foundation Property Line i DISPOSAL PONDS ❑ I 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 subiect to workman's compensation taws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performancb"of the work for which this permit is issued, I'shali employ persons subject to workman's compensa- tion laws of California." The applicant must call fo all required inspections. Complete drawing on reverse side. Signed Title: Date: 4 FOR DEPARTMENT USE ONLY :.b, i Application Accepted by Date QD rea I Pit or Groui Inspection by Date Final Inspection by edaate Additional Comments: ti r' Applicant•- Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ,,1601 E., Hazelton Ave., P Q�Box2009, Stockton, CA 95201 FEE AMOUNT�DUE ' AMOUNT,FtEAdITTED. _ „'CK �'- ^^ - -CASH-- t-RECEIVED_BY. ,_DATE__ -PERMIT.'.NO., • FH 1�'241AEV. EH 14.2e