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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �': PERIiIT EXPIRES 1 YEAR FROb� DATE ISSUID �C�tnpletre in Triplicate) Apple-I,, 1s oh,4,bytto San Joaquin County for a permit to construct and/or install the work herein described. This application is made In ccMliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 0114p'fe � Job Address6� fr�so. Pas k, City V1*1n7 Lot Size/Acreage 9V �C o C�. Lr i�, 2�; K3 S _7�a Owner's Name _ f� "ClG Address SG G� 1+sw,e� �"{f _ __ - Phon 611 I f Contractor fn'G0= CC'r+ Addressyrc7�7 1491`7, t �`{��,.� `License No, �S r 31 V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ijK Monitoring Well (I 3 90t^;t ` S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1603 r2 �•` n Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l'i Public fa Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by _ _ w E AV_rT rwrr7a=__=nn_-(-fv t-r l Repair Work Done L7 Type of Pump H.P. State Work Done )F GSA! xn- Well Destruction ❑ Well Diameter Sealing Material k Depth 1Tb'L IS.> L y&to rj ,lr 6- Pk v Depth Filler Material 8 Depth Oy rL T�f1{ S► C• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I 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 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 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 compensal tion laws of California." The applicant must all required inspections. Complete drawing on reverse side. ' Signed X Title: H r f, Date: / `7 F R D ARTMENT USE ONLY IT) (?Y Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Oate 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, Stockton, CA 95201 FEE INFFqi�O, AMO�V}NT DUE AMOUNT REMITTED %CK RECEIVED BY GATE PERMIT'NO. EH 13-21 tREV.,/n51 �Ih o EH 14•26 t� (�( L