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APPL I CATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Public Health Services. Job Addressql1 V !� t +✓ 1 ^ — Cit O Lot Size/Acreage // t Owner's Name �LYG)K �� � {..51�Y`��'fl. Address 6/ PGpSrA r"4 phone 42 Contractor 1 �h Address ��r5�-y� (_�Frl License No.r29 �&_�Phone a� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 400 • SEWER LINES DISPOSAL FLD, PROP. LINE.2=92�� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSQ ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS n Industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing j Domestic/Private ❑ Gravel Pack C] Tracy " -�- _ Type of Casing. _-<T,-e_ I'1 Public C7-Other ❑ Delta Depth of Grout-Seal /�� Type gf Grout m, em"V I I Irrigation <_Approx. Depth "�1,f,I Eastern Surface Seal Installed by,lJfl�r��fT.�IL, 11-G Repair Work Done ❑ Type of Pump I k.P., e;k State Work Dane-' Well Destruction ❑ Well Diameter Sealing Material & Depth - Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is `• vh available within 200 feet.) �J Installation will serve: Residence_ Commercial�,; Other Number of living units: ._____ Number of bedrooms Character of soil to a depth of 3 feat: ia Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments , PKG. TREATMENT PLT. ❑ i' L Method of Disposal x �? Distance to nearest: Well 7-1 Foundation Property Lina LEACHING LINE LI No: & Length of lines Total length/size FILTER BED C7 Distance to nearest: Weil Foundation —'Property Line SEEPAGE PITS 11, Depth f Size Number JC I SUMPS ,l.l Distance to nearest: Well Foundation 'Property Line DISPOSAL PONDS ❑ + I hereby certify that I have piepared 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-fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall not r� employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature l 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 re wired 'nspections-Complete drawing on reverse Signed Title: �„_.- Date: + _ FOR DEPARTMENT USE ONLY Application Accepted by 1'111A ) Date -7iL ID Area Pit or Grout Inspection by Date Final Inspection by SAL L Date 9 2-LIM Additional Comments: oo _ 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 INFO AMOUNT DUE AMOUNT REMITTED CK I ASH RECEIVED BY DATE PERMIT'No. EH 13.24(REV,t i M sl !1 vl 7-2,5-90 Rin--, S1'�2