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APPLICATION FOR PERMIT p� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 pFMT EXP RES 1 YEAR FROM DA ID (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 made 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 Address 3pa.— Lt eAl1 --Z S7` City Ad� Lot Size/Acreage Owner's Name _ E� y' kg LL _ Address x}94 F �gAlr-.y L_A) Phone s' Contractor r� ��Address 7 YI, A9>6cIS ?` At16 License IVo.Sh Y7 *Phone - TYPE OF WELL/PUMP: —NEW WELL D _• T WELL REPLACEMENT ❑ DESTRUCTION ❑ Uut ofrt erring Well service Weli, D PUMP INSTALLATION ❑�.� . SYSTEM EPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC,TAN 'LINES DISPOSAL FLD. PROP. LINE ' FOUNDATIONf A ICULTURE LL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM A A NSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private ❑ Gravel Pack ❑-Tracy.- - Type-of Casing Specifications I`l Public 1:7 Other fl Delta th of Grout Sea! Type of Grout I I Irrigation T _ Approx. Depth t I Easter Su a Seat Installed by Repair Work Done U Type of Pump H-P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Maters & Depth Depth Filler Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION (V REPAIR/ADDITION I I DESTRUCTION I l available�w thin 200 feet.led if public sewer is Installation will serve: Residence f✓Commercial_ Other ! � �� / Number of living units: Number of bedrooms 7� I Character of soil to a depth of 3 feet _ 261-Al D y Z_&10" ' -- ' Water table.depth. _Z_ SEPTIC TANK Type/Mfg- L- Capacity 1 V C No. Com,partrnents PKG. TREATMENT PLT. ❑ / Method of Disposal Distance to-nearest:. 1V Foundation °J Property Line t p LEACHING LINE No. a Length.of lines 2- ^ Total Is ngth/size FILTER BED C] Distance to nearest: Welt Foundation �- Property Line SEEPAGE PITS Depth ! Size S r Number -,7 SUMPS LI Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS 0 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 must call for all requ.ed inspsctio Complete drawing on reverse side. �} Signed X _ Title: Date: -7 :Z- 9- 2 - -- R DEPARTMEN7.USE ONLY U31pplication Accepted by , Date O Area Grout Inspection :, __ Dates �UFinal Inspectiorrrn Date byr '� Additional 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO � �� y q �y f a EH 53-24cgEV.IIh51 /�� Or C b—fv9— /0 17&—le,g� EH 14.16