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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 O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRO 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 1862 and the Rules and Regulations of San Joaquin County Public Health ffSe__rvices. r. Job Address ST[f u I City G SCR�O Lot Size/Acreage/0 AC Owner's Name —�ldrrY�J. r`b S 5{ Address _( � 7 t-1/t C q � Phone V—3 Contractor dr ! f/I I'�gl r�S 1� �2Yev / y� ��} y a !� A dress dl /�O License No. 0 SI Phone O �7 L�377 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 9L SYSTEM REPAIR ❑ OTHER O 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 _ n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private fiO=hveel•pack El Tracy Delta Depethof cast 9 Seal- _$ r1 Specifications, I'l Public (] !' Type of GroutAEL ate I i Irrigation g' _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done {J Type of Pump _'t_�_nq_ .. H. _ 1 State:Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth D Filler'Mate-rial & Depth \ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No—septic system permitted if public sewer is y available within 200 feet.I Installation wilt serve: Residence_••` Commercial— 'Other'- Number Other'Number of living units: Number of bedrooms 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 Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 'Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify 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: "! 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 taws 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 Californi ' The applicant ust call for all re d ins ons. Compl to 3yawing o verse side. Signed Title: ,�. Date: X,0 USARTAUNT.USE ONLY Application Accepted by _ ; L Date. a Area PitCGroutne ction by to �� Final Inspection by y� r v Dat9� -V Additional Comments: cz — 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 AMOUNT DUE AMOUNT REMITTED CK INFO �} 1 CASH RECEIVED BY DATE PERMIT-NNO. . EN 1J24IREV.riXSl i4 / [oV EH tt-2E on.