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APPLICATION FOR PERMIT F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 , EXPIRES 1 YEAR FROM DATE ISSUED j (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 City Lot Size/Acreage 3676 Owner's Name 1P/ ! ��p dress Phone �� "" [r3 i " Contractor ` ddress License No. ' �Phone TYPE Of'WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ P w> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C1 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKF� SEWER LINES DISPOSAL FLD ,��- PROP. LINE -3.,.- -- —FOUNDATION-, -AGR ICU LTURE-WELL__r" .OTHER WELL ,PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA`, CONSTRUCTION,SPECIFICATION ( 1 F industr6l.Yi� ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing Vomestic/Private )OGravel-Pack t.- 0--Tracy-T —Type-of�Casing --- G- — �pecifications t I'1 Public C] Other n. n Delta Depth of Grout Seal _ �16� Type of Grout / JL,• ��Q j i....J I I.Errigatian! _ AppraK. D_epth I.I.-Eastern', Surface Seal installed by Repair Work Done ❑ _i Type of Pump �I. H.P.. f State Work Done r Well Destruction ❑. Well Diameter I t Sealing Material & Depth f t Depth ftT?, , € Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic,system permitted if public sewer is 771r available within 200 feet•1 G Instailiition will serve:i Residence 7=="*CWrK0rc1al Other Number of living units: Number,of Ldroom5 °.4 - ----- .,.,£ Character of soil to a depth of 3 feet:r " { Water table depth SEPTIC TANK. ❑ Type/Mfg* Capacity t°-• No. Compartments f PKG. TREATMENT PLT. Cl Method of Disposal 1 Distance to nearest:: Well. Foundation Property Line LEACHING LINE 4❑ No. & Length of lines4 ti Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size NumberA SUMPS 'Ul Distance to nearest: Well Foundation Property Line DISPOSAL PONDS •f❑ I s I hereby certify that 1 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 t 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." f t The applica mu I req ui i ions. Complete drawing on rave se side. f Signed X Title: �- Date: C A RT - Application Accepted byCDDate Area Pit or rou Inspectionby Date�i� Fintil Inspeciion by �'�_ '��7�J Date A' �vf Additional Comments: 4.11;`51 G/ �'o ��1Y/d f� a �,z"�a/�T�f{ .Qr/�rd 1r��✓t� Gc��/F�CP9r�/l�o/t'. l.�fc os�rj/ Applicant - Return all copies to: San Joaquin C unty blic Health `�- Services, Environmental Health Permit/Services ,1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE _fINFO MOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY GATE pPERMIT NO, . EHt3-24 1AEV.1/95) EH 14.26