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APPLICATION FOR• PERMIT k p �`Y— REIN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �—} < AUG1 5 �� ' ENVIRONMENTAL HEALTH DIVISION L 1601 E. HAZELTON AVE. , - PHONE (209)468-3420 ENVIROKMENTAL HEALTH, P• o�-BOX 2009, STOCKTON, CA 95201 PERMIT/SERVICES ran■rrm EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to San Joaquin County Tror a permit to construct and/or instal.lLthe work herein described. This application is made in Carapliance with San Joaquin'county Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Hl�a.lth Services. ��ff ff nn��i^ -�/ O Lot Size/Acreage �?ft�L._— Job Address �7r1r7 E co� Y, j Owner's Name, Tl(lr Q( �_ Address 5�� _ Phone ense No., Phone ip Contractor �rJ ddress TYPE OF WELL/PUMP: `� NEW WELL �L]- WELL REPLACEMENT LJ DESTRUCTION ❑ Out of Service Well Ll a OTHER CD Monitoring Well ❑ PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ aD SEWER LINES �� DISPOSAL FLD.L -PROP- LINE DISTANCE TO NEAREST: SEPTIC TANK f P,17SLSUMf'S.- + - ,..�F04JNaAT�ON� — A�RIGULkI � REaWEial =�OTHER:WEL!»��'= INTENDED USE :kYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C} Industrial Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing ally of -- ifications ' -Domestic/Private _tl.Gravel Pack 1-J Tracy i "`�TYpe CaSpec sing , {"1 Public Gil Other (l Delta Depth of Grout Seal Type of Grout -' ' ' ZQ.Approx, Depth 171-Eastern Surface Seal Installed by N, GLFM!! I I Irrigation-. �.: State Work Done — Repair Work Done ❑ iype of Pump H. . i' Sealing Material. 8 Depth Well Destruction ❑ Well Diameter g Depth Filler Material S Depth ` TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is I r available within 200 feet,I _ i t Installation will serve: Residence— Commerciai _ Other Number of hying units: iM Number of bedrooms y --•. Y Character of sbil-to a depth of 3 feet: ' Water table depth Capacity No *SEPTIC TANK. �-�� Type/Mfg . Compartments PKG."TREATMENT PLT, + Method of Disposal Distance to nearest: Well Foundationi—f Property Line r LEACHING LINE D No. &-Length of lines Total length/size �- FILTER BED n Distance to nearest: Well - Foundation Property Line SEEPAGE PITS HCI Depth Size �� Number jSUMP,Sri _ L-11- Distance_to_nsareat.L-. Well. ti ER-ndalon __ - -�Proper�r•Line_ i DISPOSAL PONDS D ; 4 I hereby certify that I hevi 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 i Home owner or licensed a6ent'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 suchl�manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I ce ify 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 appJrus II f I all req it d inspections: Complete drawing on r rse side. c I . Till . Date: F DEPARTMENT Applicati_ cepted by Date �ri� .-- Area ��U Pit Grout I apection b�, yDate Final inspection by Date Additional Comments: L 10� ,iy' �e- ( Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 a !!! INFO AMOUNT DkJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. {r . EH 13-24(REV.iyns) I� p FH 14.215 U. IM �—