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APPLICATION FOR PERMIT l 3 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0A} Q V v!V ST ENVIRONMENTAL HEALTH DIVISION C-R-E(r- 904-1 U151lito 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, SZ`OCgTON, CA 95201 CZ a PEMIT EXPIRES 1 YEAR FRAM DATE ISSUED rf f � �r ^(Complete in Triplicate) '?��y (p 2A H t;o w� 13o r%Cr-�.3 Application is hereby a to San Joaquin aunty 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 S C-I14 tVIL.le (L D Ar s EP J City TtiAP r Lot Size/Acreage Owner's Name C''� �' rpf+c- Address $72-0 PhodZ'0 7 V:X yk 2 Contractor P� eXnc-onyfine�+/�sst423oS(n&2 /f;%4,S" cense No. G Phon�s7a TYPE OF WELL/PUMP: NEW WELL t 1 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP-INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 17) Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack IXTracy Type of Casing Specifications 'Public 1W Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation ^... Approx. Depth l I Eastern Surface Seal Installed by I Repair Work Done (J Type of Pump H.P. State Work Done o I Well Destruction ❑ Well Diameter Sealing Material & Depth I Depth Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is {� - available within 200 feet.) JU r lnstallatjon-will serve: Residence— Commercial— Other 3 .s lL. 0 6YL-/A4O—A Number of living units: Number of bedrooms 2 P 7°'7oo rr,. K. n e A x7°11 Character of soil to a depth of 3 feet: "� G"�'a War tBGlt!'�e�lft�r' SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. 0 Method of Disposal n e Distance to nearest: Well Foundation Property Line Ch1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS 11 Depth Size �.... Number SUMPS L) 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 ordinanceSr 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 subcontracting 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 applicant must call for ed insPections. Complete drawing on reverse side. Signed Title: s'h'N� 7--i 3F'ityPTA4[51% Date: 7 r Z61 X01 «'t'y /F0OfiVARTMENT USE ONLY �j 6 Application Accepted by Date J Areal Pit or Grout Inspection by Date> Final Inspection��b//y Date Additional Comments: �(r�__LfJr� °�' � b` 4 /1Li Lc%6 I TIK Applicant - Return all cope t San Joaquin County Public Health G ` /1 � �fr Services, Environmental Health Permit/Services Wi3 r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CAFEE 95201 kicd� dca ''" INFO AMOUNT DUE AMOUNT REMITTED CK REVIVED BY D E PERMIT'NO. 532 . EH13.24(REV.I/N5) �� 6 _ r EH i4-2B 444///