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APPLICATION FORPERMIT ', 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 FROW DATE ISSUED ' 1 (Complete in Triplicate) Application is hereby;0;,de,to San Joaquin County for a permitKto construct and/or install the work herein described. This application is made in"compliance .Wlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. I Job Address i A7(0 f T City Lot Size/Acreage 1,6o ae e Owner's Name _ t A dress �`�®p " �' � Phone 33 r'90"O" i Contractor { Address /� C Cense No, ` a�hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ € PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER p Monitoring Well {� DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES� DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑;Manteca Dia. of Well Excavation Dia. of Well Casing Domestic!Private,..s ,❑_Gravel Pack �..:.L7.Tracy = ' Type of Casing Specifications ' �-y J x f'1 Public Y 1-1 Other '� 1-1 Delta Depth of Grout Seal---A,-' Type of Grout I 1 Irrigationy L Approii. Depth I 1 Eastern •. Surface Seal Installed by t ' Repair Woik Done-C] Type of Pump H:P. f State Work Done_ i Well Destruction c) ?Well Dia---er'4 g 4- �"; ASea_'ng ldaterial,&_A. epth f 4 Depth �� Filler Matbriel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION_I-I-REPAIR/ADDITIO'N " DESTRUCTION AlNo septic system permitted if.public sewer is 'vailable within 200 feet.) installation will serve: Residence Commercial Other r I` Number of living units: --,IL-- Number of bedrooms Character of soil to a depth of 3 feet:} r Water table depth SEPTIC TANK ❑ - Type/Mfgs``r Capacity—1-19-00- No. Compartments 2 PKG. TREATMENT PLT. ❑ +;r r Method of Disposal 'I 6961 ce-to nearest: ti Well ^ Foundation Property Line �Q LEACHING LINE D- No. & Length of lines Total length/size FILTER BED ID Distance io nearest:�� -Well�40 Foundation Property Line SEEPAGE PITS 11 Depth Z _5iie � fo �� Number4. �•v ¢. SUMPS Ll Distance to serest: WBII Foundations Property Line _ 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 certifies 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 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." ` The applicant must for all require spe t• 'Complete drawing on reverse side. � M SignedTitle: _ _ Date: 4 A� 17 L TM f R DEPARTMENT USE ONLY Application Accepted by DateL�� Area x t+r } t Pit or Grout Inspection by Date Final Inspection by—n �ad , Date Additional Comments: f j e G•G / Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 777 1601 E. Hazelton Ave., P 0 Box'2009, Stockton, CA 95201FEE S/ INFO AMOUNT DUE AMOUNT REMITTED CASH K 0 EK RECEIVED BY DATE PERMIT'N0. ♦ EH 13.24[REV.1/n 5) � � �--!•�� I 1 ,� M� (/� 4 I� 24<1 �•}� EH 1/-20, I r ti.P l� f`J