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I APPLICATION FOR PERMIT wSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION• `1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EMIT EXPOS 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 application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address l o()o g, r P DE 7 City y Lot Size/Acreage Owner's Name A J a CA _(L Address cau 62d ,(V Phone- - 313 7 i C415 Vt,? _Tt Contractor _ Address 7 7~7 �15 (-LP one " + 4 TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT n- DESTRUCTION ❑ Out ,of Service Well �❑ � 4 -- --PUMA_kNS�A1LATION ❑ SYSTEM REPAIR ❑ OTHER Q gonit�o�r`inng Wel-1 (j,'4 +, DISTANCE TO NEAREST; SEPTIC TANK _ JCJd- SEWER LINES' DISPOSAL-FLDf ti=.PROP. LINE_ FOUNDATION d AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i1 a/ tr � //QQ y Typa of Casing �--� Specifications t D Industrial pen Bottom ElManteca Dia. of Well Excavation Dia. of Well Ca_sing es /IKDomestic/Private ❑ Gravel Pack C7 Trac _ t 159 --- +- �'.._,_� l't Public ' f Other C1 Delta Depth of Grout Seal SD Type of "Grout_ f= I I Irrigation _..AppraK�eterj Depth .I 1 Eastern Surface Seal installed by Repair Work Done ❑' Type of H.P. "-Work Done Well Destruction ❑ Welt Di Sealing Material f: D t j I Dept Filler Materi Depth i- TYPE OF SEPTIC WORK: NEW INSTALLATtON I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is S� available within 200 feet.1 � Installation will serve: Residence_• Commercial_ Other , Number of living units: \„Nu'mber R of bedrooms C Character of soil to I1, of 3�feet: '' ' Water table depth SEPTIC TANK. 0 T e/Mf r" '" (� YP 9 ' -Capacity No. Compartments ! .v PKG. TREATMENT PLT.Cl (' Method of Disposal Distance to near ;Well ° ` _ Foundation # ° '� t' Property Line f LEACHING LINE` I D No. & Le Itof lines.-0 �R Total length/size -FILTER BED ' El' Dista a to I nearest: Well Foundation Property Line P Y SEEPAGE PITS I I epth Sire d Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS •'" `�- ••q I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county c rdinances, 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 rermit 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 o sub-contraining signature canities the following: "'I certify that in the performance of th ank-.for wh Bch this permit is issued, I shall employ persons subje to workman's compensa- tion laws of California I r, ,r I' The applicant must q ii pe +' .-�e; plete"3dtawing on reverse sides Signed X � #:t B; ! Date: of R DEPARTMENT USE ONLY - 4, NLY -4,�� ) Apation Accepted by A, Dategree Z-- - Pit Grou Inspection by Date �� Final Inspection by DataQ'� - Additional Comments: r Applicant - Return all copies to: San Joaquin Cotmty Public Health _—�-- --- Services, Environmental--Health-Permit/Services--'rt" '"--r' + 1601 E. Hazelton Ave.,, P.0 Box,2009, Stockton, CA 95201 t INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. . EH13-NIREV.r,ti51 l.lq ; ~�7 , EH 1424 t"O c