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APPLICATION FOR PERMITr ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " i ENVIRONMENTAL"'HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420:._".- P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1, YEAR FROM DATE ISSUED (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 //�� City t Size/Acreage n Owner's Nam Address �Lf . Phone Contractor ��"`� Address 7 V I��__g 1 ! License No.C�/4Z ,j3one_ �-574 TYPE OF WELL/PUMP: NEW WELL yam!" yF WELL REPLACEMENT _ DESTRUCTION Out of Service Well ❑ - " INST -- ---- � �'��"� � PUMP ALLAT��ION5YSTEfv1 REPAIR-❑ OTrFiER.,D__ Monitoring Well,f� C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.S�_ PROP. LINE `f' FOUNDATION �� AGRICULTURE WELL ` OTHER WELL PITS/SUMPS 112.0 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavatio Dia.of Well Casing k t6meslic/Private ravel Pack L1-Tracy—. �Type of Casing / Specifications I'I Public Cl Other �n-D�eit '' Depth of Grout Seal _/�� Type of Grout I # Irrigation + _ Approx. Depth (<t'Eastern Surfce Seal Installed by ` Repair Work Done UType of Pump '� ' H P. t�� State Work Done _ CC jM _ Welt Destruction Iii k'Well Diameter —� Sealing Material i Depth / Depth, t Filler'Material a< Depth TYPE OF SEPTIC WORK:._NEW INSTALLATION-1-1—REPA-IR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence Commercial_ Other (�i Number of living units: Number of bedrooms \,� M1\' Character of soil to a-depth'of 3 feet: ` Water table depth SEPTIC TANK. ❑ Type/Mfg a R. '� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation- Property Line Q F J I j LEACHING LINE C1 No. & Length of lines f Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS i 11 depth Size l --- Number Q SUMPS } Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El Ii ! I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations a Joaquin County 3 Home owner or I' nsed agent's ignature certifies following; "I certify that in the performance of the work for which this permit is issued. I shall not employ any son in sudh man r as to.- a ei, ubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the ollowind: "!certif hat in rmance of the wo k-4or Which this permit is issued, I shall employ persons subi.vt to warkman's compensa- tion laws Californi ." The app)- ant must all F all-re r I piece drawingo r r aid - Signed — Title: -� pate: FOR DEPARTMENT USE ONLY ; 7 - 3 r Application Accepted by Date Area y ` Pit or Grout Inspection by Date Final Inspection by / Date Additional Comments: l/V d'r"< L l/l C.s Applicant - Return all copies to: San Joaquin County Public Health • t t2 f t Services, Environmental Health I?er /Servi s ! r � 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. a EH 13.24 Mv.I/is 5) 7/3 { EH 14.20 ti