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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P 0 BOX 2009, STOCKTON , CA 95201 PRUIT_EXPIRES 1- YEAR FROM RATE. ISSUED, (Complete in Triplicate) Application Is hereby main *4 San Joaquin County for a perrzit to construct anti/or install the work herein described. This application is madce with Sart Joaquin County Ordinance No. 549 and 18612 and the itules and Regulations of San Joaquln County Public Health Services. JobAttdrass --�_ f_1 LIP_ . !"` Y City Y"- p L r e Wt Size/Acreage I hereby certify that I have prepared this application and that the work will be done in accordance with Sats Joaquin county ordinances, state taws, and rules and regulations of the San ioaqLin _County HOMO owner or licensed agent's signature canifias the following: "I canify that in the performance of the work for which this parmit is 44084, 1 shall not empioy any person in such "ringr as to become subject to workman's compensation laws of California, " Contractor's hiring or sub -contracting signature certifiers the following: "I certify that in the psrforrrtautce of the work for which this permit is issued, I shall arrtpooy persons subject to workman's compenss- tion Iowa of California." Applicant - Returo all copies EH 13.23 1AEV. 1 r r S) EH 71.38 to: San Joaquin County Public Health Services, Environmental Health Permit/Sezwices 1601 .S, Hatteltoa Ave., P 0 'Box 2009, Stockton„ CA 95201 Date: Arae Date ?/ FEE Akli)UfdT DUE Owner's Nama�� a EKa" d(es Phone Contratt6rAddress I Ty.VL,itene Mt)��1'lttsnt r TYPE OF WELL/PUMP' NEW WELL 0 WELL REPLACEMENT DESTRUCTION (.i Out of Service :tell ,0 -- PUMP INSTALLATION 0 SYSTEM REPAIR C OTHER " Monitoring Well DISTANCE TO NEAREST: SEPiIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i l Industrial 0 Open Bottom Cl Manteca Dia. of Well Excavation --- Dia. of Well Casing t l Dourest clPrivate 0 Gr!�vai Pack i"i Tracy Type of Casing Specifications i'! Public C! Other i"I Delta Depth of Grout Seal Type of Grout I i Irrivation Approx. Depth I I Eastern Surface Spat Installed by Repair Work hone Typo of Pump H P, Stats Work Dona _ Well Destruction D Well Diameter Sealing Material i Depth Depth' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION AREPAMIADDITION I I DESTRUCTION I I INC septic system permitted if public sawar, is available within 200 last) installation will servo: 0 Residence X Commercial — Other _ Number of living units: -L— Number of bedrooms 1 Character of soil to a depth 013 feet: lANt-2 ✓ SEPTIC TANK _-- Water table depth $, Type/Mfg E Capacity No. Comportments PKG. TREATMENT PLT. ,e,or� 0 +f Method of Disposal al ,� ..��,.rr 14PA r r Distance to nearest: Well , _ Foundation Property Lina„ ,f LEACHING LINE ` r >� 1 gt Ivo: A Length of lines Total len hfsire FILTER BED s,r .fir,-- ' C3 Distance to nearest, Wall .� Fou tion _�_ Property Lint . � _ r` SEEPAGE PITS C t Depth Sire Number SUMPS- - ~-- f;I—Distance to nearest: well foundation Praparry Lina DISPOSAL PONDS � l I l I hereby certify that I have prepared this application and that the work will be done in accordance with Sats Joaquin county ordinances, state taws, and rules and regulations of the San ioaqLin _County HOMO owner or licensed agent's signature canifias the following: "I canify that in the performance of the work for which this parmit is 44084, 1 shall not empioy any person in such "ringr as to become subject to workman's compensation laws of California, " Contractor's hiring or sub -contracting signature certifiers the following: "I certify that in the psrforrrtautce of the work for which this permit is issued, I shall arrtpooy persons subject to workman's compenss- tion Iowa of California." Applicant - Returo all copies EH 13.23 1AEV. 1 r r S) EH 71.38 to: San Joaquin County Public Health Services, Environmental Health Permit/Sezwices 1601 .S, Hatteltoa Ave., P 0 'Box 2009, Stockton„ CA 95201 Date: Arae Date ?/ FEE Akli)UfdT DUE AhtiliihT REMITTED CASH AECEiV1 D i8Y LSATE f £I'MI't' NO,, t ti , d o 1-131-1 A3 -- b b 1� 'Z_.