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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 r P O BOX 2009, STOCKTON, CA 95201 PF+MIT EXPIRES 1 YEAR FROM D � JU (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 Services. Job Address F ZI�Nyen-MMW--4- - C-OVK-C City slot-r-Vonj Lot Size/Acreage S-c.I1.Ne4.y CiQ Owner's Name MACK _ Address Sr 0 t ior�n-+�rlh r r� +c� 95126 Phone p 1 �NGRO4�-fJ/�aJr.:f 11S Contractor Bpt >�r 11.,, Address3`rr°�O"te� G.UIe Sv,ie�S 'f57 L?cense No. 5 i�`�y� Phon 916 fall-9 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION C1 Out of Service Well ❑Monii PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER 6�.reaAJo`ring Well ❑ AL 13cQaais, DISTANCE TO NEAREST: SEPTIC TANK J SEWER LINES uIPI DISPOSAL FLD. 141A PROP. LINE -UJA_ - ..- -- - FOUNDATION _ lllh AGR ICU LTURE-WELL A- OTHER WELL rJA PITS/SUMPS --06 - �- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Li Gravel Pack C7 Tracy Type of Casing Specifications I.1 Public Other n Delta Depth of Grout Seal Type of Grout I i Irrigation (0:5 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Dona"oTF-c "'CAL. BofLMC-S to-151_ Well Destruction ❑ Well Diameter Sealing Material & Depth W+TM r 8��D I Depth Filler Material & Depth a p 11-L.C-,IULrr AOL'5 TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION i I (No septic system parmitted it public sewer is P available within 200 feet.) (arl`5FIRri RLAI04 installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth k f SEPTIC TANK. ❑ Type/Mfg Capacity-- No. Compartments `'f PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SIJMPS LI Distance to nearest: Well Foundation . ,Property Line f DISPOSAL PONDS ❑ 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 cenifies 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 or sub-contracting signature I 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." I! The applicant must call for all required inspe tions. Complete drawing on reverse side. Signed X �l/rl'l7 Cr.`/ �t Title: Date: F R=TME T USE ONLY I Application Accepted byPLDate Area 9 r 1 q Pit or Grout Inspection by Date Final Inspection by r J Date �- Ir,,,, r Additional Comments: e°Q kn� fitCco /-Q �' �� LC' - c 2 T� 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 I CK RECEIVED BY DATE PERMIT NO. INFO ('� p �'+y �C^ASH ]L ♦ EHt3-24SREY.'IK5) / XV! Qb J � ,a q '"61� I EH"s4-26 lJl L LLL...JJJ I