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APPLICATION FOR PERMIT SAN JOAQUIN ,COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION F 1601 E. HAZELTON AVE. , PHONE (209)468-3420 � P O BOX 2009, STOCKTON, CA 95201 PEUIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -� 'Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heat Services. ,, Job Address `�>cLt-1 Q:kt '_City A Lot Size/Acreage a Owner's Name G2 t `��' —�--]rt _ Address rt- -_-- Phone .. ! ,� t.�t41` 5 �� `37(�S�'7 _.Phone 2� Contractor�•A,t�41 flO�L: �i✓i..tlhr1'9ddress nL�J.�„ G�j License No. TYPE OF WELL/PUMP: NEW-WELL-A�----WELL-REPLACEMENT, DESTRUCTION,❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ -Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK 2nQ SEWER LINES DISPOSAL FLD.� PROP. LINE 4716 i FOUNDATION ____;— AGRICULTURE WELL OTHER WELL PITS/SUMPS k � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIgNS n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` {'1 Public [.1 Other n Delta Depth of Grout Seal �© Type of Grouta I I Ir(iOation Approx. D th l I Eastern Surface Seal Installed by W _ T Repair Work Done 0 Type of Pump��H.P. 2— State Work Done Well Destruction ElWell Diameter Sealing Material Depth G Depth f Filler Material & Depth -. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION i I 'Wo-septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— ,Other Number of living units: Number of bedrooms 1. is Character of soil to a depth of 3 feet: Water table depth _ } SEPTIC TANK.` 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D, 5 t � Method of Disposal ! Distance-to nearest: Well Foundation Property Line 1 LEACHING LINE CI No.& Length of lines Total length/size ` ' 1 FILTER BED ' ❑ Distance'to nearest: Well Foundation Property Line � SEEPAGE PITS 1.1 Depth Sire Number SUMPS LI Distancetonearest: Well Foundation Property Line - DISPOSAL PONDS Cl y I hereby certity 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 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." The ap all fo all required in tions. Complete drawing on reverse side. Signed%Y.. .. f - Title: t ' C 'i�"l l Q�C� ih I Date: Li ..; T DEPARTMENT USE O_ NLY- { 1 Vr� iAppfication Accepted by Date Area Pit orrou Inspection by. Date l Final Inspection by Dat�j � �( t Additional Commerts: — , y Applicant - Return all copies to: San Joaquin CountylPublic Health a, '""`Servrices;'Environmental 1#ea7.th�Permit/Serv3'oee"-- •- "`--�� .� 1601 E. Hazelton Ave., P 0 box2009.,,Stockton, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK It INFO CASH RECEIVED BY r DATE PERMITN0, j ` 13.24(REV. 5) r _l�J,Rj� � Q S� 7/V 7 ` v JU T lelwo t 94211 .---