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a, x APPLICATION FOR PERMIT L� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 RMIT 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 Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County�Publiisc Health Services. Q f Job Address 7iJ / Nw��v City cSIOG oO_ _ Lot Size/ creage �IC] Owner's Name _ + LV;O S�1.t/ /' Address 70 7 w PhoneL Contractor Ji. Address 2 suet SCI License No, 3CJO Phone 7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION-C]_— .x,,, ,:SYSTEM REPAIR ❑ . _ _ OTHER p _ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES DISPOSAL`FLD. PROP. LINE FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE ORWEtC ,� PROEILEM AREA CONSTRUCTION SPECIFICATIONS F- industrial Open Bottom ' O Manteca Dia. of Well Excavation IR Dia. of Weil Casing 12' Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k I'1 Public Cl Other C1 Delta Depth of_Grout Seal ,�f2` Type of Grow ECttc it p6e 14 rrrgalion w Approx. Depth I I Eastern Surface SeaE Installed by _r,,,rL,Z Repair Workt5ne ❑ Type of Pump WP, State Work Done Well Destruction ❑ Wall Diameter Sealing Material & Depth G Depth_ - Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other R Number of living units: Number of bedroomsr Character of soil to a dept!Distance 3 feet: ater table* th j SEPTIC TANK-" ❑ p Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal to netlrest: I undation Property Line LEACHING LINE Li 'No. & Length of.lines - Total length/size tt .,FILTER BEI] ❑ Distance to est: Well Foundation erty Line } SEEPAGE PITS I epth Sire _ Number ) SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PON 5 ❑ ,r , i 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 F employ any person in such manner as to become subject to workman's compensation laws 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 shale employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required ins coons. Complete drawing on reverse side. Signed Title: _ _ _ Date: _9—I ob FO. DEPARTMENT USE ONLY Applicpn"clrlon cceptsd by / Date r-. b 4 `' Area t Pit or byWt Date Z z d r Final Inspection by Date ^� Additional Comments: 4 S Tom' G Applicant - Return all copies to: San Joaquin County Public Health Services, Firivironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N07 CH+ EH 2�IIREV.tins) n" E�