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R0-U(ZN ki-M'7-TO, ADPL I CATION FOR PERMIT RAIU-j (rExq-E1-{Au r c,An1, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES xTro- orwk StuaiCen- ENVIRONMENTAL HEALTH DIVISION -3{76 ;a0.�S—iglINi- S'wA 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Ws:.� SA-e.ftAtAG&'`�f CA P O BOX 2009, STOCKTON, CA 95201 ISMI a o. EXP RES 1 YEAR FROM DATE ID G`li6)�7)-CA 3y Q rAJ t-'-' (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Service 4,:)7- 2 OF STbc.�"•iaN ��tQ.?IoRT P�St►sa�S Pi4(�IC. Z. ,Ek�S Job Address t' � Ze1�cc�eal O "t F�GGK � V, City S'ZxA(� Lot Size/Acreage '3, Owner's Name .tt �T&SGn)TVR-P9-,5ES19ddress cAtA&.te^7r0j CA 5iE528 Phone 3f,k,S CyAgf- GIef—Lrz,SQ4'Cr=,e ContracIA-li f f Uu * �+9C.Address Lft Cet2.3 0%(1 S License No. 5 �Zg Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK WA SEWER LINES 2-!�f 'i-` DISPOSAL FLO."&- _ PROP. LINE _ FOUNDATION NII - AGRICULTURE WELL -q-&— OTHER WELL--yh— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack L) Tracy Type of Casing Specifications Il Public Cl Other fl Delta Depth of Grout Seal Type of Grout ('` a I I IrriUation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 T1ype of Pump H.P. State Work Done . Well Des ruction ❑"=1MeHCbiameter 7tf't Sealing Material dr Depth xPl,,c�Tl Z t iA Depth jp"IS t Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION t I lNo septic system permitted if public sewer is available within 200 feet,) 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 ❑ No. & Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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, ant 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 taws of California." Contractors 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 compensal tion laws of California." The applicant must tali io I required inspections. Complete drawing on reverse side. Signed X Title: STAI=F ENI f�fz Date: F[ K��3Tc Y Ca,�aT�C-kf�lfCAL FOR DEPARTMENT USE ONLY C� Application Accepted by Date ` Area Pit or Grout Inspection by Date Final Inspection by Data s � 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 INFO AMOUNT DUE AMOUNTTJ�REMITTED CASH RREECCEEIVED BY DATE PERMIT'No. . EH 1124 IREV.i I x 51 "� ! [J1J� j ] fl EH 84.25 !! 14 1