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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 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) i 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 ` Z Z 7 C. e City Lot Size/Acreage Owner's Name` V RyZ Address ( y �/ 1U� -S Phone TL_ —` ress L 3l� Contractor t'f•( 9 Add12 ' License No. 7 ,4s Phone 33{—Y1"U' TYPE OF WELL/.PUMP: NEW WELL ❑ - WELL REPLACEMENT DESTRUCTION t of Service Well El PUMP , INSTALLATION tRe ' SYSTEMREPAIR ❑ OTHER ❑ Monitoring well f ❑ DISTANCE 70 NEAREST: SEPTIC TANK fLtl --SEWER.LINES__ r- DISPOSAL FLD. PROP. LINE W1� FOUNDATION AGRICULTURE ELL"� .OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATIONS # C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t5 jd'Domestic/Private Gravel Pack 0 Tracy Type Casing— Specifications e of Casin iV Specifications I'1 Public la Other F1 Delta Depth of Grout Seal a Type of Grout_". , + I irrigation 1,,of q pprox. Depth 11 Eastern Surface Seal installed byQ,Id � Repair Work pone 0 Type of Pump �� H.P. State Work Done m Well Destruction 0 Well Diameter „ Sealing Materlal & Depth S_CJ'Jl 264E + � Depth __ _- 70 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments h PKG.t TREATMENT PLT, ❑ Method of Disposal € Distance to nearest: Well Foundation Property Line t LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ' SUMPS LI Distance to nearest: Well Foundation Property Line f 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 j 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,-1-shall-employ persons Subjeci to workman's compensa- tion laws of California." The applicant must all for all re iced inspections. Complete drawing on reverse side. Signed X Title: -OL4,M) 9,K, _ ' Date: 1- 6— Z- i FOR DEPARTMENT USE ONLY -- t Application Accepted by Date b 'L Area__ l Pit orGroutInspection by Date$^t "O�?—Final Inspection by Additional Comments: 4 Applicant — Return all copies to: San Joaquin County Public Healt Q U_'It c7e S m�V`�cl s Services, Environmental Health Permit/Services V 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT Dt1E AMOUNT REMITTED CK RECEIVED 9Y DATE PERJZ INFf� CASH ` 12-01 `4H 13.24 IR EV.I i n W W f� 4 �+ Z r 194.2E sP.t`. 1 l , D �� ! ��b ZD r. .