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APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! Q ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERI[IT EXPIRES 1 YEAR FROM DATE ISSUED �J( (Complete in Triplicate) Applicati a 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. F Job Address A 1 M �j RA4A , +�.�_ City _ _ Lot Size/Acreage ��' 9- �IS.Z Owner's Name – i _gaeke Address P III 060A,60 gdz F Phone 0 b Contractor&&LZ"LJr 1 �c1►1�Address Q 0,&z 73 7",ff-& Ld '7AWLicense Iva.; _ _Phone d �I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well €� i -•DISTANCE TO NEAREST: SEPTIC TANK ,..100 SEWER LINES 100 DISPOSAL FLU. IZO PROP,-LINE-..J,€L._ FOUNDATION r¢ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS EI Industrial A Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing V Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing 51'67C.If Specifications--- - Z?- A V1 Public El Other n Delta Depth of Grout Seal iva , Type of Grout /h -' t l I.Irrigation I-M-Approx. Depth I I Eastern Surface Seal Installed by • Y41 4-=J/ QLiblu Repair Work Done ❑ Type of Pump 15,�,_ _ . H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth 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 - f 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 t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED C) Distance to nearest: Well Foundation Property Line k 't SEEPAGE PITS I I Depth Size Number fes` SUMPS €.I Distance to nearest: Well Foundation Property Line 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 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 compensa- tion laws of California." The applicant st c i r fl r quired insp ctions. Complete drawing on reverse side. s1�G1 9� Signed X 44A Title: r J 0 4 LZ A ZZE0 /I- Date: R DEPARTMENT USE ONLY- C�,9 Application ceeptad by ree. Date rn' U V Area s Pit r Grout y epection by �. T ' Final Inspection by // abate A -ib6al Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ' 1601 E. Hazelton Ave.,'P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH CK RECE D By [LATE PERMIT'NO. EM13.21MEV.k/n5i yf� EH 14.26 [ L i J�f5-©a mss--' C-.26,3z, _ /6 / Y/--/'/ yv