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a�. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC SEAL I TH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 40 P O BOX 2009, STOCKTON, CA 95201 REMIT EXPIRES•.1 YEAR-.,FROM DAIR ISSUED , (Complete in Triplicate)- Application is hereby made,to Sea 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 zl-_ s' t _ City g::nLot Size/Acreage Owner's Name ddress r Phone r G� . Contract& = Address- -- License No. ��- Hone I k�TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEIVIENT77 DESTRUCTI% ON-CI Out of Service Well Cl i s PUMP INSTALLATION ❑ u SYSTEM REPAIR ❑ OTHER,-❑ Monitoring Well., OtSTANCE TO NEAREST: SEPTIC TANK SEWER LINES-, DISPOSAL FLD. ` k PROP. LINE FOUNDATION AGRICULTURE.W.ELL OTHER WELL '- PITS/SUMPS INTENDED USE J TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n C7 Industrial ❑ Open Bottom ❑ Manteca I ' r r Dia. of Well Excavation Dia. of Well Casing C;l Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing- �_ _-- -- YSpecifications Il Publrc 1-1 Other ❑ Oeha � Depth of Grout Seal �� _ , p Type of Grout r .,...L ^:t. I I irrigation Approx;"Depth I I Eastern ''Surface Seai Installed by F Repair Work Done U Type of,Pum t 1 Pump H.P. State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing Material & Depth + Depth ?` Fil2er=Material &-Depth : 0 -� A , r. TYPE OF SEPTIC WORK: NEW INSTALLATION I I- REPKIRIADDITIONX DESTRUCTION I I (No septic�syslem permitted if public sewer-is available within 200 Ieet.1 Installation will serve:' Residence Commercialf_Other a -�. Number of living units: Number of be oms f XF " Character of soil to a depth of 3 Meet: 1 M i Water table depth SEPTIC TANK ❑ Type/Mfg "Capacity= _ Na. Compartments ". PKG{=TREATMENT PLT. 0 t a: + ; Method of Disposal r 3-;Distance to nearest: Well Foundation---'""—Pioperty Line LEACHING LINE ❑' '.No. & Length of lines Tota! length/size- FILTER, ength/size FILTER BED C] Distance to nearest: Well -on Property Line �� SEEPAGE PITS I I Depth Size- Number .. SUMPS L3 Distance to nearest: We Foundation 62 — Property Line DISPOSAL PONDS �W,- , ,. ` 90 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, to laws, and i rules and regulations of the San Joaquin :County = Home owner or licensed agents signatu►e certifies the following: ''Icertify 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." I The applicant m all for II req ed inspections. Complete drawing on reverse side. r Signed X—.-. Title: pate: FOR DEPARTMENT USE ONLY k, Application Accepted Area by Data �`� f� .r r.•_ Pit or Grout Inspection a '-,--DD pe b Y Date_. - Final Inspection bj ,•\t3� Datt r Additional Comments: " n _ Applicant - Return all copies.to: ,.Ban_Joaquia_County'iP� ic}Heslth - ``` ,��►►►�� Services, Environtpbntal Health Permit/Services 16x1 E. HazeltonsA:ve.. F 0 Box 2009, Stockton, CA 95201 a FEE INEQ AMOUNT DUE AMOUNT REMk1:TTED CK RECEIVED BY CASH DATE PERMIVNO. . EH 13-24 WEV.1/8 5 ��/, ! f y�DU Z EH it-24 'I- r. Yz8