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aa E. a APPLICATION FOR PERMIT � g �/' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .4— r r ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 V P 0 BOX 2009, STOCKTON, CA 95201 PFRUIT- EXPXRES 1 YEAR FROM DATB ISSUED— (Complete in Triplicate) Application is hereby made;to San Joaquin County for a permit to construct and/or install the Work herein describers. 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. Farce ( ``ti" .16 3 -0 z -l3 Job Address Next tc SJ Ri , B±h Std_ Lot Size/Acreage Owner's Name r*ress —3209 2t Ni.p_bplas --- Phone 57 —3696 Contractor Clark-Well_.------'Xddress_ 024 F. Charter License No. 371 �6ip-__ Ptlone TYP�EOF WELL/PUMP: NEW W_ELL..C].�-^^ WELL REPLACEMENT ❑ -'- --DESTfiU_CTIONK[Rgut of Service Well ❑ � 7NTALLATION ❑ SYSTEM REPAIR ❑ OTH'ER C7. Monitoririi-Well C1 DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES F DISPOSAL FLD. PROP.-LINE- f FOUNDATION, ' "r AGRICULTURE WELL!.• OTHER-WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS n Industrial ❑ Open Bottom C1 Manteca �X'E Dia. of Well Excavation- ° Dia.'of Well Casing [] Domestic/Private ❑ Graves Pack 0 Tracy Type of Casing- tl Specificaticins 4 n I'1 Public la Other 71 Delta Depth of Grout Seal Type of Grout I I I Irrigation l Approx, Depth I I Eastern Surface Seal Installed by r Repair Work Done 0 Type of Pump H.P. State Work'Done 1 Well Destruction # ❑ Well Diameter 4 & 6_"_ Sealing Material & Depthpar GP;Rp 2 wellS Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTI o septic system permitted if public sewer F available within 200 feet.M Installation will !serve: Residence Commercial— Other + Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L-1 Method of Disposal t_ Distance to nearest: Well Foundation Property Line LEACHING'LINE 0 No. & Length of lines Total length/size x � FILTER BED'S ❑ Distance to nearest: Well Foundation Property Line ? SEEPAGE PITS 11 Depth Size Number ; - SUMPS f 0 Distance to nearest: Well Foundation Property Line t ))} DISPOSAUPONDS ❑ 1 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 fff rules and regulations of the San Joaquin County Home owner,orlicensed 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 laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I ce t i performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor is. The applicant I It ired Ctions. Complete drawing on reverse side. Pti Signed X Title: Mark Well In, Date: 1 FW DEPARTMENT USE ONLY 2- nnj Application Accepted by �i�� ._� Date Y] -1 ,J Area Pit or Grout Inspection bye _ _ _ _Date Final_Inspection_by_ &,,_ --Date -•- - X70 r � Additional Comments: �- Applicant - Return all copies to.,_.Sen Joaquin,County Public Health Servi_ces,_Environmental Health Permit/Services ._T_s-1601 E.JLase`iton Ave., P 0 Box 2009, Stockton, CA 95201 FEE WED A OUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMFT'NO. �{ r + EH 13-24IREV.tiw Si GL eH3—�O gb- D� � fH i426 i ° ��, 111