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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 0 BOX 2009, STOCKTON, CA 95201 RZMI,T MIRESI YEAR FROM DATE ISSUED (Complete in Triplicate) A fA/SO-) —I/0 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 Count Ord#�nannc-�eQQNoo.�.., 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 9�a L�.p ``�7-�7 Job Address - City I �`R C Y Lot Size/Acreage ^eu, G►'+~ Co Ly Fri>r r�z �� k1RO0 ner' N me / Address Phone P Yd s TVLACy IA i>o 7a,Iz i'7-r� Ph 1� .q2�' 1 �=C-& AddresSy Contractor XC(=, S2!or�15 on�4rF �T-q-License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,� Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 9 SO f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a0a-7/-- I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Hq ly' L-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Yo ! Cl Domestic/Private ❑ Gravel Pack 00 Tracy Type of Casing Specifications F) Public C] Other F1 Delta Depth of Grout Seal Type of Grout_?_0n4R /k'"20 I i Irrigation ____ Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ !C,- Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200}eet.I ---- Installation will serve: Residence_.. Commercial— Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK.. ❑ Type/Mfg Capacity. Na. Compartments Com' PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, an 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 n 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 applicant must call-for-all`-required inspections. Complete drawing on reverse side. f �1 Signed _ Title: 5FAA_"VL- F7e,-La tF41()74,Jfr—V —Date: .5-1 �,a 6_` � O G��! OR DEPART !E USE ONLY _ Cf IT) �d��/� O2-Z0 Applicatio Accepted by Date Arse G� Pit or Grout Inspection by Date Final Inspection by Z< Date s C Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1641 E. Hazelton Ave{, P 0 ox 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ; K INFO RECEIVED BY DATE PERMITNO. . EH13-74 IREV.r/x 5156 y rte— /✓!L S 2 f � Q�_A2F