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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. 1 PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s 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. l Job Address 91 � ��S2/ r1 Rd City 14 y 1z�4. Lot Size/Acreage + t C✓�'. !'�raZZ%F Address �� Phone Owner's Name %'1� Contractor z/3//t - r Address 1 0, e��1?�� License No. �� "�'� Phoney TYPE OF WELL/PUMP: NEW WELL S9 WELL REPLACEMENT ❑_ DESTRUCTION ❑ Out of Service Well ❑, PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well r DISTANCE TO NEAREST: SEPTIC TANK 'r-4- SEWER LINES �C DISPOSAL FLDC!rQ',-k PROP. LINEIS-_ FOUNDATION —'� AGRICULTURE WELL_ OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,& n Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing -/�3 C Specifications � cr-12)Oi— ("1 Public 1:1 Othgre.� (l Delta Depth of Grout Seal /0� �G9Type of Grout -� I I Irrigation ��.Approx. Dept,h,. --I�1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. f State Work Done_ Well Destruction ❑ Well Diameter "'Sealing Material & Depth Depth Filler Material & Depth -S 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments1 PKG. TREATMENT PLT. ❑ Method of Disposal �T Distance to nearest: Well Foundation Property Line L- LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant nrpt call for all requ' d ins ctions. Complete drawing on reverse side. Signed Xfi�/•2 -�`I'�'L� (.,;.�st��?`L�= Title: `r-��/`-3C2—IC/" Date: P /r rFQR DEPARTMENT USE ONLY Application Accepted byDate ID -Area Pit o G�out spection by Date -f Final Inspection by Datpeq ��o Additional C )a ta: 'Lt/^17l`ct� .l.//'EC /o o � �v E c rfi/�j'c O/ •IvCF..1�E�.�i /�d�,ss✓�9�f�/�f/�..fE.f/1�-�T.�ir�.C.�iEO i 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 AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'N0. INFO CASH 1�3 EH 13-24IREV.iinsl C - � y � 1435 EH,b2a