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APPLICATION FOR PERMIT * j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON; CA 95201 PERIdIT EXPIRES 1 YEAR FROM DAB ISiBD (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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /�� Job Address , C/Lf 7_f5 ��0/f L� /F"� �!"i'e4plity, Lot Size/Acreage � Ils!� P.O. e s��i��,,c�'S"!o Owner's Name Address /' �� - — Phone Src fs ' � c# 70� yS1-- 92I CDntractor �ZX �l�'1�� Address ��O �9��_ _Liceslse No.� Zig Phone TYPE OF WELL/PUMP: NEW WELL F, WELL REPLACEMENT (7DESTRUCTION D Out of Service well Cl PUMP INSTALLATION D SYSTEM REPAIR D OTHER D Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK y'¢ SEWER LINES DISPOSAL FLD. A114 PROP. LINE -1`Z0 - - - - FOUNDATION AGRICULTURE WELL OTHER_WELL.- - -PITS/SUMPS ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing IjfJ�(f t�D PdG W1 a& lD rd P Domestic/Private D Gravel Pack n Tracy Type of Casing _ Specific ions 1 Public [c�'Other fl Delta Depth of Grout Seal 2 T�i�IGlC Type of Grout Dom`/ u r I I Irrigation WApprox. Depth l I Eastern Surface Seal installed by f�'jc �� 5 /—"L Repair Work Done L3 Type of Pump <-4rMk HH1. State Work Done_ Well Destruction Diameter �� Sealing Material & Depth ��7l �cr f Depth "-_<0 017ff7- Finer Material & Degth/ �"�<�A1 7r/�1f ,Olt+ i3J�op�orsvcyc TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I k INo 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 i SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED C] Distance to nearest. Well Foundation Property Line SEEPAGE PITS l I Depth Size Number -. SUMPS- .- El-.Distance-to nearest: Well - .Foundation.-- -- - Property.-Line - - DISPOSAL PONDS Q 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 at 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." Theapplicant must call fo II i inspections. Complete drawing on reverse side. Signed A Title: Date: l0 : Q UFOR DEPARTMENT USE ONLY Application Accepted by Date 3A Area Pit or Grout Inspection by X �r Date Final inspection by � Datel-3 IL— Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009 tockton, CA 95201 10 FEE AMOUNT DUE AMOUNT REMITTED CK1 D 0Y DATE PERMIT NO. 0 V5 CL INFO CASH EH 13-24 1pEv.i I m 51 1., �J !� hJ)ekL, /a4 EH 14.25