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F-9-TUF40 Ps4LM it APPLICATION FOR PERMIT �I��v CS►>�U'Cc�-�I1�/I[�3L SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES tea' 10kk 6AL ZIE2�L ENVIRONMENTAL HEALTH DIVISION 31-76 1M0Q`T7>Z1A1- SI-VO 1601 E. HAZTLTON AVE. , PHONE (209)468-3420 -ZA4 MENi1>rC-IN P O BOX 2009, STOCKTON, CA 95201 CIS0 f E%P RES 1 YEAR FR !ii DATE ED (`4 ib) �-71 'Ou13+4 (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. .CDT 5 ter sTaIn_eeToM 1!1 RPo;a-r B.)SINasS ?ARK Job Address �U1t)1T S lZec,td��1 7Ah2 W Bc"Lcz 3r_�j�City Lot Size/Acreage _ SIS EL��L CO-ar-V. 7 Owner's Name T7�5 kr27C (4665* ddress + CA '?S E26 Phone (9)6�38�r3 Q Contractor 0F l�«^Lf�` ��lddress License No. Sly�2� Phone 91b 6 j- 5q TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well L"1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring well DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES 70t+ DISPOSAL FLD, NA PROP. LINE -olk— i FOUNDATION AGRICULTURE WELL _1 —" OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-) Industrial L7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout +, I I Irrigation —Approx. Depth [ I Eastern Surface Seal Installed by 1T, Repair Work Done ❑ Type of Pump H.P. pS�ta�t�e Work Done W@II Destructia ❑9-Diameter yI+"l' Sealing Material & Depth 'ir (.+�iMFz1�T of, I�JzrV�dltii 6eotF GXPL.COJ CCl,j 60"14(,S Depth fid' I Filler Material & Depth �F �QL7LIWL�u 1Tz� _ �ti .1TT>:�1=L� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other i Number of living units: Number of bedrooms Character of sail 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 I, LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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, anc 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatun 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 required inspections. Complete drawing on reverse side. Signed X- Title: 5'r/ FF- &V6fPJF.1FR Date: y/ 6� FF"_ RA' CN 6E4>T6G}1)NiC*L_ ( FOR DEPARTMENT USE ONLY �y5 Q r Application Accepted by �J1N1B,2c_ "t-+� Date y— t� Area Pit or Grout inspection by Date Final In1spection by Date �r Additional Comments: %Z 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. . EH 13-24 IAEV.1/N 5)SB EM 14-26 1 y. f