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APPLICATION FOR PERMIT 1N SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ©� ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE 1§aUED (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. y�� 7353 Gh�r^� ��e� ! �C City�S1CTC►(Ok?_ Lot Size crease 204-323 Job Address f Owner's Name �Y l cora Address �a-�'e- ,...._.._..... ._..�.. Phone S!' /Z 3 Contractor T� T-xS c-Isgi-S -_. Address 4/72 SlLkn&0 V- License No. '3001 y Phone_711 112 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Gl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK 21QQ • SEWER LINES mop DISPOSAL FLD. — PROP. LINE 22_ FOUNDATION _41� AGRICULTURE WELL — OTHER WELL-==— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria! pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z/� [.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 29m Specifications 411A- -- T, Other f 1 Delta Depth of Grout Seal uf7�, ` Type of Grout_��r h' �a I ng ion �.Approx. Depth I I Eastern Surface Seal Installed by ,-UL; ' r Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is f V available within 200 leet.1 w Installation will serve: Residence— Commercial— Other Number of livor iLg Number of bedrooms Character of soil to a depth o t: Water t epth W SEPTIC TANK D Type/Mfg Capacity o. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foun Property Line LEACHING LINE Cl No. & Length of lines at length/size FILTER BED ID Distance to near Well Foundation Lime _77 SEEPAGE PITS epth Size Number SUMPS LI Distance to nearest: Well Foundation Property1ine 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 taws of California." Contractor's hiring or subcontracting signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall employ personssubject to workman's compensa- tion laws of California." The applicant must c it for all r wired ' spections. Complete drawing on reverse side. / p Signed X Title: - Is1 ....._ - DTate: -I 01- f� F DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by �, 5�'L�pata Final Inspection by Date Additional Comments: 2�- Applicant - Return all copies to: San Joaquin County Public Health i Services, Environmental Health Permit/Services ----:__ 1601-E...Hazeiton--Ave:, P-0-Sox_2009, Stockton, CA. 95201 FEE INFO AMOUNT DUE AMOUNT RE/MirrEED CASN RECEIVED BY /DATE PERMIT'NO• r EH^3-24{AEV.,r/.HSI _ �'�0�.._..._ .t.'� g�3 EH .4.2E