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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r, r ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 1Z 1)6 P 0 BOX 2009, STOCKTON, CA 95201 PMMIT EXPIRES 1 YEAR FROM DATE IOUEDS (Complete in Triplicate) fApplication is hereby made to San Joaquin Count fora • Y 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. � �,q Job Address v[YJb 1�v" "' Y� City tr `r'4`D� Lot Size/Acreage l0 ' Owner's Name A0R'EW PAUL 'V-linvi5!<1 Address 1100 Ml i ek R 0AD rN1t p "A 6Z 1 2 01\9'71O --C 7 Phone Contractor � � Address 000 LAsI License too. Phone TYPE OF WELL/PUMP: _ NEW WELL Eir WELL REPLACEMENT, 0 DESTRUCTION ❑"Out of Service Well 0 PUMP INSTALLATION-C- _ SYSTEM REPA OTHER ❑ Monitoring Well L� DIST;4NCE-TOWEAREST SEPTIC TANK` 1' EWER"LINES — DISPOSA FCD_+'_9 PRD"P"LINEGN�'' FOUNDATION S ti AG ULTU ELL4000 OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS a 1 F�'/(IndustrialOpen Bottom eco a. of Well Excavation K Dia. of Well Casing2ihnflEs _ / lir Domestic/Private ❑ Gravel Pack Tracy Typ .of Casing 2LnAl74C- P1-E Specifications _ I'1 Public Specifications Other I-1 Delta Depth o rout Seal ICO Type of Grouf""'" M " t I Ir6gation _ prox. De th I I Eastern Surface Seal Iled by e E Repair Work Done c`�T ype of Pum _ Q� y.P. Sta Done Well Destruction Well Diameter Sealing Material & Depth i Depth 2$O� Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTAL TION REPAIR/ADDITION I I DESTRUCTION I i pt—(No ,. ic system permitted if public sewer is Installation will serve: Residence� Commercial Other available within 200 feel.) Number of living units: Number of bedrooms +n Character of soil to a depth of 3 feet: �' Y't►^ t,.. �© SEPTIC TANK. ❑ Type/Mfg Capacity Water table depth �-L�- �� pp,,��,,,,,, PKG. TREATMENT PLT. ❑ y�"`"`"'INo• Compartments Method f Di osal i Distance to nearest: Well Foundations Property Line J9 - LEACHING LINE & Length of lines E otallength/six6Atp"�'' FILTER BED ti si; f Distance to nearest: WeiI Q!%. �; Foundatior:,� Property Line'- SEEPAGE PITS __X41 DepthI A1*01E___S ize gt Vumberw SUMPS ` Distance to.ns rssWell - Foundation DISPOSAL PONDS ._ � Property Line Cs 1-hereby certify tharl have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la �y rules and regulations of the San Joaquin County ws, and Home owner or licensed agent's signature certifies the followin em to an g: "I certify that in the performance of the work for which this permit is issued, f shall not ploy y Person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-Contracting signature certifies the following: "6cartify 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 u call for all required 'nspeetions. Complete drawing-on re side. Signed Title: J oc r!7 "2 i Date: F R DEPARTMENT USE ONLY r r Application Accepted by G-*.,. A Date Q 1 C Area it r Grout Inspection by Date J Final Inspection by �}�J )r Dats ' Additional Comments: *A,plic t - Retur all e a to: San Joaquin County Public Healthtw Services, Environmental Health Permit/Services�� 601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK E' AMOUNT DUE AMOUNT REMITTED O+ CASH RECEIVED BY DATE PERM17'NO. . EH 13-24 IAEV.r/nst + 4�. im, 0o > •� - EH 71-28 1�v