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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 < r,�r,-ID PERMIT EXPIRES 1 YEAR FROM DATE IS$UED (Complete it 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. 5h9 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. pL,rm o F Ou it4otin vz22Y 2c4p Job Address Lo T__ City i'o LSC Y_ Lot Size/Acreage Lia ,moYi Y Owner's Name r-JIN ! A VA 2 R G� Address 1+2-5 �t Q�eW c�j, r� Phone 49� ` 0 60r ! Contractor 1�JI)IN-C&PILtMP CQ Address e License No.,5_02 73 __Phone /7 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ i. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial Cl Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing s C] Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public f:7 Other ❑ Delta Depth of Grout Seal Type of Grout 1>('trrigation _.Approx, Depth I I Eastern Surface Seal Installed by r,- Repair Work Done X Type of Pump :LTZZ131 IT H.P. I-C-6 State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth �� 4�.a f7 Tam fir— 4 NC Depth Filler Material & Depth 1 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I I (No septic system permitted if public sewer is F available within 200 feet,) r- 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 } SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments ~ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size i FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number i SUMPS 0 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 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 applicau II for all re wired,inspections. Co ate drawingon arse ,de. Q Q Signed Title: Date: % ! , USE ONLY I DEPARTMENT Application Accepted by _ r'"Q'�� „ ,,. ... Date ` ,Area Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECE! D BY DATE PERMIT'NO. I . EH 13-24[REV.r/K 11 r £H 14.20 L�k — C7-