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APPLICATION FOR PERMIT 'I i SAN JOAQUIN COUN'T'Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT .EXPIRES 1 YEAR FROM DATE I-SSUBp {Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This &pplication 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 T 13 i City Lod j Lot Size/Acreage Owner's Name "C-9c, �� _ Address Phone (Qq FrO 7 0 Conlractor4vlo245 Lt1E a R Address)2 F" 1- , License No. 23 r. Phone 7 5-AD TYPE OF WELL/PUMP: NEW WELL fK WELL REPLACEMENT E DESTRUCTION tut of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK ZOF- -SEWER LINES -Sib . : _.DISPOSAL FLD. J', ..PROP. LINE EC FOUNDATION AGRICULTURE WELL a0t) r OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial Open Bottom ❑—Manteca Dia. of Well Excavation Dia. of Well Casing [.1 Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing S - _r L Specifications I'l Public El Other n Delta Depth of Grout Seal ' - Type of Grout I 1 Irrigation 15D-Approx. Depth I 1 Eastern Surface Seal Installed by 9 4.S`O4- r 4 Repair Work Done U Type of Pump H. t State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 4,v1 TYPE OF SEPTIC WORK: NEW INSTAUv LLATION I I REPAIR/ADDITION I 1 DESTRUCTION I t INo septic system permitted it public sewer is I} Installation will serve: available within 200 feet.I Residence! Commercial— Other Number of living units: Number of bedrooms { t Character of soil to a depth of 3 feet:1 Water table depth SEPTIC TANK ❑ Type/Mfg Capacit Y No. Compartments PKG. TREATMENT PLT, ❑ }1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size / FILTER BEDC) Distance to nearest: Well Foundation ProCID perty Line PIN SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Lina f I hereby certify that I have prepared this Application and that the work will be done in`accordance with San Joaquin county ordinances, + rules and regulations of the San Joaquin I'County state laws, and 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." T The applicant t coil It r req fired spe.ctions. omplete drawing on reverse side. i .R Signed Title: ,C_. © vim- Date: F R DEPARTMENT�USENLY Application_ cepted by Date �Q 1 i� S Area Pit Grou nspection bAME Date Final Inspection b 61 / f Date Additional Comments: U� v�� - N tt.>P - iva Applicant - Return all copies to: 'San Joaquin County Public He y / (J lservicee, Environmentalth Permit/Services 1 1601 E. Hazelton Ave., 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED lNFO C SH RECEIVED 8Y DATE PERMIT NO, + EH 13.24 MEV.t K 5 1 �7 ',')��-fj 1 �"i to 4! EN 14-26 N S V 1 r ' 1 �R7 1 1� L•� -Q �1�