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4 r APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROWNU NAL HEALTH DIVISION PAYMENT 1601 E. HAZELTON AVE. , PHONE (209)468-342'RECEIVED P O BOX 2009, STOCKTON, CA 95201 APR 1 a,tsso ,PERMIT EXPIRES 1 YEAR FROM DATE ISMUN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES Application to hereby made.to San Joaquin County for a F IVR IVMENk HE�ILTH pIVl N. pp q permit to construct and/or ins a work ere n describe 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. ��',�� a C+�� Job Address As"/Y L,AGrr'oQo �� , 40-600 Cqty-ruse , J`7Lot Size/Acreage ild 7ixk/&&14 $11""-e, I e r ff. "s 40 Owner's Na a s 2 Add R.O. 120 9 G4 Phon i0l 8 36-6":Z7? .:„. ontracto assLicense o. ne TYPE OF WELL/FHMP- NEW WELL ❑ 70 AAIA95XVS04ME NT ❑ DEST ffLXIIof Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER MoitoringWell U G e e&"".,ca./ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I& 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��'�jor� jJ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3J/y'�PYG C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing/— mt Vii!Domestic/Private ❑ Gravel Pack )4Tracy Type of Cining� F JyG Specifications � I"I Public [,Other n Delta Depth of 'f 30 35SCf Type of Grout_��tr'sr I I Irrigation 3Q Approx. Depth l I Eastern Surface Seal Installed by Repair Work bone L] Type of Pump H.P. State Work one,T Well Destruction ❑ Well Diameter .Sealing Material � Depth Fe�IJf,YMil Depth �Dift✓ a- l 16.6:2 pw w-T IF& 9r+ 4.� a sem- G, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INoseptic system permitted if public sewer is ,l �available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT ALT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f=oundation Property Line ti SEEPAGE PITS 11 Depth Size _ Number w SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 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 required In petitions. Complete drawing on reverse side, Signedned Xfi/ r. �Title: t•✓_y' /+r- .�B.�14F2! .� 6+�wwDa�te: s-.`..�.�wy � i4 EPARTMESE ONLY Application Accepted by Date �~ Area Pit or Grout Inspection by bate Final Inspection by Date Additional Comments: _ 74 4 Applicant - Return all copies to: San Joaquin County Public Health Services, ftvironmental Health Permit/Services 1601 Z. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED 8Y DATE PERMIT N0. H a EK 13-21 fflEV.119 5) EH 11.2a "1 1