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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAO3EALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) E� �c-I- ' I 9)3_ 2-150 -a 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 . 49 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��,� Job Address _ City � hot Size/Ae Owner's Name rass l rpt/t !4'� `- L i� � Phone 1 y � Contractor ' 1*//JS Address License No,1&f" Phone TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI % SYSTEM REPAIR ❑ OTHER ❑ Monitoring , 1 C] DISTANCE TO NEAREST: SEPTIC TANK lel SEWER LINES r` DISPOSAL FLO. -- ~ PROP. LINE D FOUNDATION AGRICULTURE WELL —OTHER WELL �^ PITS/SUMPS _�C/ f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S A 1/ 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing W Domestic/Private ravel Pack 0 Tracy Type of Casing_ Specifications n^ V1� I'i Public f:7 Other n Delta Depth of Grout Seal Type of Grout I I Irfigation �WApprox. Depth II iEastern Surface Seal Installed by___,,_._ Repair Work Done 0 Type of Pump �[� H.P. �� State Work Done Wel! Destruction 0 Well Diameter Sealing Material 8 Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION VI 'REPAIRlADDITION 1 I DESTRUCTION I i INo septic system permitted if public sewer is `•. �., t C + avaitable within 200 feet.I Installation will serve: Residence_ Commer�ia!`�:_,- Ofher 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' --proparty^Line LEACHING LINE Cl No. & Length of Gees Tot lenq hAixe� FILTER BED CJ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth +' Sire Number SUMPS LI Distance to nearest: Well Foundation ��Property Line t--\ �'• DISPOSAL PONDS Cl —� ---t s I hereby certify that I have prepared this applicai on and that the work will be done in accordance wifN'San Joaquiri".,couAlVkordinances,Atate`laws, and s rules and regulations of the San Joaquin Count ; tisk= k Home owner or licensed agent's signature certifiesthe allowing: "I certify that in the performance of the work"for�ni lxich tiffs. e�mit_jis ued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.-Contractor's hiring or sub-contrictirig 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'sicompensa- tion laws of California." P The applicant Or, requir i S. Complete'drawing cinre.vors4Lsido. Signed X ills: �p T USE NE CI Application Accepted by Date Area VkV - Pit or Grout Inspection by Date j Finsrl�nspectA Iyy _ ate Additional Comments: 11 �' ! C D /nok_ 5 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 CK if OR CASH RECEIVED BY DATE PERMIT'tVO. EH 13-24{REV.t/nSI 64,6 Qf'— 77Z. Q�// EH: Ie 4- P� h V 70