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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES {r, ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 PAYMENT P O BOX 2009, STOCKTON, CA 95201 RECEIVED _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f1"R (Complete in Triplicate) SAN J0AQU1 TY Application is hereby made,to San Joaquin County for a permit to construct and/or ineta {¢`� e1 41�rde�s �{ i This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an �c �1IR �a�t d�l�ll$#ai n Joaquin County Public Health Services. yJ y� Job Address `► (0 06 Wei _ Sof(�l^TL= City M04C& Lot Size/Acreage I Owner's Name �� AddressG�? fic.�ST J -1 V LT r� i�D Phone gds 09 I Corlco raP Contractor I V G i LIY+`�1v► Address t�Q��$1V��-l� �} License fVo. C� Pone �b S ro(21 TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 4R6 ¢TH� . Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. cry f1 f41AE Z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public is other n Delta Depth of Grout Seal 30 dT Type of Grout 6Lgal-Ce+siert* I I Irrigation „,„,._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ �4 t Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 6' available within 200 feet.) ' installation will serve: Residence Commercial Other Number of living units: Number of bedrooms 1 l 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 f lines g o nes Total length/size FILTER BED ❑ 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 wilt 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 of 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 Californi ' The applic II for I qui ed ins ions. Complete drawing on reverse side. Sign Title: 1 S 1Pry7r5 1V7�e1— Data: F R DEPARTMENT USE ONLY Application Accepted by Date 0 Area Pit or Grout Inspection by Date Final Inspection by Data 7 rL 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 INFO AMOUNT DUE AMOUNT REMITTED CAH RECEIVED BY DATE PERMIT'NO. + EH t3-24 MEV.+i n sl F -p2 rEH 4•2e4,26-w01JJ � � ' G!� O—1 i�-