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WIR APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3920 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lr� . (Complete in Triplicate) Application is Hereby ma6eto 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 1562 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressWtIET- Flt (t -15�3�1CM kCity <,lb*-M Lot Size/Acreage r2A c-# �7Twt-! IDVU r11aJ1. 4n - NAL- i'IC3a`-I�i`��SG�3 Owner's Name Address J� yC Phone 93`4Zl>✓ OGL1 C0Ur-AJA1C-AQ5'74Z cc�� Contractor g F T10� Address�3iGMF�' Q&. License NO,51014Z6 Phon 1 J� -958o TYPE OF WELL NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well n PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER� Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES irn DISPOSAL FLEI.001t PROR�NE 34t�� FOUNDATION 100�--t AGRICULTURE WELL IjVL- OTHER WELL, PITS/SUMPS lap!-t- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Welf Excavation Dia. of Wel! Casing ua 'D//oo�meesiic/Private lD Gravel Pack Ci Tracy Type of Casing._ - NA Specifications- �_ _ \ f'I Puk3lie f&1lZQZtful XOTher�IgelK16p f-1 Delta Depth of Grout Seal �� Type of Grout.-.1JA (f�, r - - " I i Irrigation .Approx. Depth I I Eastern Surface Seal Installed by"A Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter sealing Material & Depth rs=iltaSiE Ikby)A.w-15ewux)f 37 V\ Depth 'Zo 11 Filler Material & Depth CAAT"t.1e1S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is available within 200 teet.i Installation will serve: Residence T Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water Ti�14 SEPTIC TANK ❑ Type/Mfg Capacity No. C PKG. TREATMENT PLT. ❑ Matho o( is 0al' Distance to nearest: Well Foundation Property ifa 4 19 3 JOALIW LEACHING LINE L-1 No. & Length of lines Total len HEALTH, FILTER BED CI Distance to nearest: Well Foundation Property Line �� DlVfsl 't 411 SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS 0 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I camly chat 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicants call for required inspections. Complete drawing on reverse side. Signed X / Title: C /f - - i Date: _�15E 2.! FOR EPA ENT USE ONLY Application Accepted by IDate _ � � ArsL—y �Pit qr Grout Inspection by Date Fina! inspects n by , S f � I Additional Comments: T-- 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 0 s INFO FEGElJEa BY PATE PERMIT NO £H 13.24 MEy. n s q r FH 4.20 a,' 8 i Cl� oil