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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES „ . ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOA 2009, STOCKTON, CA 95201 PERMIT EXPIRES- 1 YEAR FROM. DATE__ISSUEDD (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 1862 and the Rules and Regulations of San Joaquin County'Public Health Services.I P ,�y, )A j Job Address r ! � � D oy-�_efo City e'�` Lot Size Acreage 4 `'' t+ i Owner's Name G�ey,fb V\ 0 S QS �G Address 3. Z p Ca,yY►1'Mfb t�gmMf2n ��^^' P o^e �s d ,� f [�v4Gr :C3g� �1 i-tJ+�+t �74V f.�S�.; ,� Contractor4� ykAwAc Address^ovrftjY � '4 � License No. Phone " 2-3 ! TYPE OF WELL/PUMP: NEW VVELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well P. PUMP INSTALLATION ❑ SYSTEM REt�R 11 OTHER ❑ Monitoring fell �f DISTANCE TO NEAREST: SEPTIC TANK LAIV'-_"�hSEWER LINES DISPOSAL FLD. K_K� _PROP. LINE FOUNDATION �A'f^'v`AGRICULTURE WELL �L�---MOTHER WEI.Li"k C-� ITS/SUMPS YiOrc3� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t"] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' Dia. of Well Casing V Domestic rivers ❑ Gravel Pack ❑ Tracy Type of Casing�o-v�aw Specifications } I'I Public KOtherftj S ,y c(, ❑ Delta Depth of Grout Seal i,— Type of Grout T LAA-1 r i I Irrioation &_L Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump 1r1•tlyt-4- H.P. Y1 b, - State Work Done h.O lam, Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public suwar is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms IJ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ 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 Foundation Property Line V. SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest; Well Foundation Property Line i DISPOSAL PONDS ❑ 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 1) 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 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant 9wot call for r ui ed inspec, ns. C^omplete drawing on reverse side. r / Signed d �`� Title: 46-e n[0 �j Q5 Datq: 1E� o . / FOR DEPARTMENT USE ONLY Application Accepted by „^^�e'e Date llblqo Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE Y INFO AMOUNT DUE AMOUNT REMITTED CK 1111 CASH RECEIVED BY DATE PERMIT NO. . EH 13-24IREV.t/A51 - f .".S_ '} 't} jf-"i f } ry