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AP)L I CATI ON FOR PERMIT SAN. JOAQ1JI*-.CQLA1 C HEALTH SERVICES f"r1tf4 h +* �4„�„ *` w ENVIRON 'AL TH DIVISION r 1601 E. HAZfiLTON AVE SHONE (209)4B8-3420 $fit, s •. x P O BOX 2009, .STOCTON CA 95201 -r �” PERYIT EXPIRES 1, YEAR FRt •-iDATE ISSUED (Complete in Triplicate) Application is hereby made. 0 oaquin County for a permit to construct and/or 'install the work herein described. This application is made in comphi ce with Bea Joaquin County Ordinance No. 549 and 186 and the Rules and Regulations of San k Joaquin�Cbunty Public Health 65,2 a. +.� Job Address City Lot Size/Acreage Owner's Name ddr"ess..r" __ 'r ` : Phone 1 Contra ctorddresscense No, <rPhone Jam ' TYPE 0"F WELL/PUMP: NEW WELL ❑ _ WELL REPT AC MFNT" n DESTRUCTION ❑ Out of Service Well .❑ 4 r{ -�,�.�.,-Moni'tori.._ PUMP INSTALLATION ❑ SYSTEMTREPAIFiv OTHER ❑ n8 L7 DISTANCE Td NEAREST: SEPTIC TANK SEWER LINES DISQ9ALfFLO. PROP, LINE 4 FOUNDATION AGRICULTURE WELL OTHER'6V LL PITS/SUMPS {{ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFlCATjONSz i F) industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Grave(�eck C7 Tracy Type of Casing Specifications i I•I Public Ci Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth' I I Eastern Surface Seal Installed by Repair Work Done U Type of'Pump H.P. State Work Done_ Seals Material & D t ;Well Destruction :❑ Well Diameter n8 Depth Depth Filler Material"& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR"/ADDITION DESTRUCTION 1.1 INo septic system 6 p permitted if public sewer is ' available within 200 feet.} x* *• _ Installation will serve: Residence_ Commercial_. Other Number of living units: Number of bedrooms �� r 1.Y. — •. 'd -:v.4. Vit.,. Character of soft to a depth of 3 feet: _ Water_table depth SEPTIC TANK 0 Type/Mfg f l # I Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ -e Method of Disposal s d Distance to nearest: Well Found on'2.« "�Prpperty Line LEACHING LINE ❑ No. & Length of lines Total length/size r ` FILTER BED 0 Distance to nearest: Well_ Foundation�� Property Line. " SEEPAGE PITS 11 Depth ! ' Size Number .... SUMPS Ll Distance to nearest: Wel!�'°Foun tion Property Line y';< DISPOSAL PONDS i7 I.k ZZ47 •rc ` l I hereby certify that"I have prepared this application and that the work will be done in"acCdPdance-with_San Joaquin county ordinances;,t is laws, and y 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,#shall not employ any,person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractang";signature certifies the following: "!certify that in he performance of the work for which this permit is issued, I shall employ persons subject to workiiianSs cortipensa tion laws of California." s' r.. i • •,The applicant mus II for akitguirad.ins clions. Complete drawing on reverse side. i Signed X t y , » g Title' ' � Date: ► r +� R a DEP_ RTM NT USE ONLY _ AcZpledlo, d by r r �y ;Apr�calron Date _ 42, Area ou in byate �tFrttal Inspection by �.1 _ d:► 4 Additional Comments: Y z e„Applicent.- Return all copies to: San Joaquin County Public Health # Services, Environmental Health Permit/Services +.<_ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton CA •, w 95201 ,x-.. FEET 'AMOUIJT OtJE AMOUNT REMITTED CK RECEIVED BY DATE'?5' PERMIT'N0. I INFO � GASH } EH 411{REV, In 51 C EH 14.26 �J