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Y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMNTAL HEALTH DIVISION . 1.601 E HAZFLTON �AVE. , PHONE (209)68-3420 � PO BOR 2009 STOCKTO 4 N, CA 95201 BUM= 1 YEAR FRQM DATE ED - j. (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein deser bed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Pu lic Health Services. Job Address City ZZn141t, Size/Acreage Owner's NameAddress +,-.iw - sem.-... ,'V,� 0 '7j - . Phone r Contractor -Ir Address License No. Phone ! I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT..0DESTRUCTION ❑ Out of Service i1e11 ❑ tT PUMP INSTALaTION ❑ SYSTEM REPAIR O a OTHER ❑ Monitoring well C7 I DISTANCE TO NEAREST: SEPTIC TANK j SEWER LINES I _DISPOSAL FLD. PROP. LINE FOUNDATION ` ' ° ' AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l7 Industrial CJ t open BottCa Manteca " Dia. of Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of-Casing— Specifications -- ." fit Public - 1-1 Other fl Delta h Depth of Grout Seal I I Irri atian Type at Grout-� t?' —.Approx. Deprth I I Eastern # A eSurface Seal Installed by Repair Work Done C7 Type of Pump 1 H P .t„_ r f_ Well Destruction, _ ❑ :-Well Diameter ; _Sealing Material rE De th State Work Done Depth Filler Material pth T1.YPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AD'Df710N i ' DESTRUCTION 114No.septie system permitted it public sewer is i '' available within 200 feet.! 1 lnstaltatian Will seive. Re`sidence`� Commercial Other ' Number of living units: Number of bedrooms L Character of soil to a depth of 3 feet' •' . + ~'ter` SEPTIC TANK. Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll _ Method of Disposal Distance to nearest: " Will- "' _-- ' -' Foundation "�'" µProperty Line LEACHING LINE Cl No. & Length of lines FILTER BEDTotal length/size C7 Distance to nearest: J Well Foundation —,Property Line SEEPAG PITS 11 Depth i Number `'' - ' I 7PropL7 Distance to nearest: Well tion DISPOSAL PONDS - ❑ erty Line d i .� c�•r i ✓' f CL�a k I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and'll rules and regulations of the San Joaquin County, } e> i Home owner or licensed agent's signature certifies the following: "I certify that in the employ any person in such manner as to become subject to workman's compensation lawsoof Californiarmance of . Contractor's work for rmit which opsub-contracting e is issued, lsignahu�e certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall om to t tion laws of California." E p y persons subject to workman's compensa- The applicant m cal r e ire in pe. tions. Complete d Ing on rev a ide. Signed ' ills: - Date. ' FOR TMENT USE ONLY Application Accepted by Date -1 Area Pit or Grout Inspection by i DateS E.?%rf�6✓d�r oddd�9iyly�yyEr � Final Ins action b Dates O Additions! Comments; 1! add e i l G/ �c �/r✓ .a �o�6X7-511. Applicant - Return all copies to: Pubw - op San Joaquin County lic Health-,.. .- Services, ES vironmental Health Permit/Services ~4 FEE 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 jry� >f CK INF AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO, + EH 13-24 1REV,