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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 BOX 2009, STOCKTON, CA 95201 PFRUIX %P RES 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1371 City ,704NrrCA, C4 Lot Size/Acreage ' 4C Owner's Name _ MA, JgrRA ?n00RE _ � Address F-0. 00A 67 4AVr.1 C,9 9530 Phone 2o9�vP3S r AANC,40 01 40111111 C9 737VR Contractor ja r Pvtotf co,,? Address 3 oMEC CN[tL4",s A . License No. s /7 1VQ PPhonet!/_ t: TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ;N DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM RE�PIR L.7 OTHER ❑ Monitoring Well G4 DISTANCE TO NEAREST; SEPTIC TANK N /� SEWER'LINES t* 60 DISPOSAL FLD. /y/A PROP. LINE R y6" i FOUNDATION NS AGRICULTURE WELL !A OTHER WELL n 3 00' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .XNC ES Dia. of Well Casing I:1 Domestic/Private III Gravel Pack ❑ Tracy Type of Casing ScAafwle 0, lw— Specifications f'1 Public [:1 Other f 1 Delta Depth of Grout Seal 13 /s Type of Grout r C��ret�r I I Irrigation 14Approx. Depth I I Eastern Surface Seal Installed by Q f 400T0*/_ ,itr Cc'Y/° Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter a -T'VO4r,S Sealing Material k Depth Depth S Filler Material & Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION 11 (No itted if public tic s stem permsewer is t t available within 200 feet.) V Installation will serve: Residence_ Commercial_ Other f Number of living units: Number of bedrooms i 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 _�4 LEACHING LINE C1 No. & Length of lines _ 9 Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line L' t DISPOSAL PONDS ❑ to I hereby certify that I have prepired this application and that the work will be done in accorjance 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 empioy any person in such manner as to become subject to workman's compensation laws of-EelioFga."Contractor's hiring or subcontracting signature (o 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 all teauired inspections. Complete drawing on reverse side. Signed x Title: PAjiyc;?,,*L h'yda � ,s�` Date: 6- 9b F FOR DEPARTMENT USE ONLY Application Accepted by Date.__(6 Z� C7 Area 7 3 a Pit rout nspection by Date 2sFinal Inspection by__ _,ef,04:u� Data 'z . p� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Healt Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Bo 2009, Stockton, CA 95201 INFOFEEAMOUNT DUE AMOUNT REMtTTED C H CKJ RECEIVED BY DATE PERMIT ND. . EH 19.24 IREV,I/x 51 EH 14.26 O O