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�,. *,1111 fit. *k "'t$�1� '� ' , "�l'��, .4 4 rr Y ; APDL T CAT.I ii y IRt r:Y! • - tom. 6� � a�+�w�41 � i� �� i.. 4 �r ��A,�i�; a SAN JOAQUIN COUNTY„PrUBLIC,;HEALTH SERVICES EN V I RON1dEPITAI, I3EALT DIVISION 1601 E. HAZELTON -AVE. , PHONE (20 )}458.-5420 IV-It P O BOX 2049, STOCgTON, CA 95201 ExP RE -:1 YEAR FR M DAT � pp9jj9YY��n (Complete in Triplicate)90.� U V r install the work herein described. This Application is hereby made.to San Joaquin County for a permit to construct and/o application is made in compliance with San Joaquin Co ty Ordinance No. 549 and 1862 and the Rules and Regulations of San o Joaquin County Public Health Services. I City Lot Size/Acreage Job Address Q tPhone i Address i Owner's Name �— � �, Ole P Contractor Address f� ra v License No hone ` NEW - ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ TYPE OF WELL/PUMP: 3 OTHER C] Monitoring Well ❑ t; PUMP INSTALLATION © SYSTEM REPAIR 4rY r ISEWER LINES. -DISPOSAL PLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK 1 r PITS/SUMPS FOUNDATION AGRICULTURE WELL. - OTHER WELL d ii INTENDED USE TYPE OF WELL PROBLEM AREAy'h'CON$TRUC710N-SPECIFICATIONS Dia. of Well Casing C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications s Type of Casing , �l Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout i'1 Public C] Other (-1 Delta Approx. Oe I i Eastern Surface Seal Installed by '4Q Irrigation i State Work Done -,Repair Work Done )6 Type of Pump H.P. -, Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Materia]. & Depth Depth _ %. TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR1ADOlTION I 1 DESTRUCTION I l afvailabl,9 witseplic hin 20stem 0 feettled it public sewer is M 4 Installation will serve: Residence Commercial_,..� Other l r V� f Number of living units: Number of bedrooms r Water table depth Character of soil to a depth of 3 feet: a' Capacity.,..-.--- Na. Compartments€` SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ dproperty Line Distance to nearest: Well Foundation - j Total length/size. LEACHING LINE ❑ No. & Length of linesroperty Line FILTER BED 0 Distance to nearest: Well Foundation w SEEPAGE PITS 11 Depth Size Number i SUMPS LI Distance to nearest: Well Foundation "` Property Line DISPOSAL PONDS ❑ is application and that the work will be done in accords�ce with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared th rules and regulations of the San Joaquin County following: "I certify that in the performance of the work for which this permit is issued, I aha not Home owner or licensed agent's signature certifies the employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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'scomp sa tion laws ofCal' a." i I The cant mus all for all required i tions. pie drawing on n side. o, Title: Date: r`, Signed i s FOR DEPARTMENT USE ONLY' ' �' s Date rea ' } A Iication Accepted by r Pp t.. p _ r ,�•.,...-= to -Final Inspection by " ` fla Date; �= Pit or Grout.inspection by kA - - 4 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 CK RECEIVED BY DATE +�4 PERMIT N0. FEE f ffE! OUNT DUE AMOUNT REMITTEDCt EH 13.241f1EV.r/R51 EH 51.2e