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0 APPLICATION FOR PERY10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SKAM3S/iMU ENVIRONMENTAL HEALTH DIVISION �I.tIlV3H �d1N3WNOb1�3N 1601 E. HAZELTON AVE. , PHONE (209)468-34`ld COP !P lu'(nM O BOR 2009, STOC%TON, CA 95201 1766 � o Nn r, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) QBA1usA3�t i0� F�3.//,H.a Application in hereby made to San Joaquin County for a permit to construct and/or Install the vorll-Nz�11aAMflfed. 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 Addres/6-Sr Sewy "k CLtr-okee La4in.L City t—Od 1 Lot Size/Acreage f�cwGk-e-I( �W ,,gasLn(o Owner's Name eYµ�"��dr¢es's �oyS-S z r/s^2 Yu�« rf'�`�-y��Phone �S 3 PD so -R4 (a/U Contractor t 111h Address Li neof, o0, 415698' License No.� ,�63YPhone TYPE OF WELL/PUMP; N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ $y�M REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _M;k SEWER LINES 00 r DISPOSAL FLO. IJA PROP. LINE z dh1 W '7� FOUNDATION 9 S-I AGRICULTURE WELL _AI� � 4 OTHER WELL / PITS/SUMPS 11r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS it LI Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Gravel Pack ❑ Tracy , Type of Casing f Ve ,Sr."_ H0 Specifications •��S�o� Il Public fl,0ther nDelta �r Depth of Grout Seal r' • Type of Grout o Y'•*�'.�(•'Jf• I I Irrigation 710 Approx. Depth I I Eastern Surface Saul Installed by aiA+ / S114 PNy Repair Work Done ❑ Type of Pump H.P. hi A, State Work Done _ A Well Destruction ❑ Well Diameter Sealing Material i Depth 2 n {sf OnS Depth 2 Filler Material i Depth TYPE OF SEPTIC WORN; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is \ available within 200 feet.) 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 ` I SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Linen LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS 11 Depth Size Number 7 SUMPS LI Distance to nearest: Well Foundation Property Line '\ DISPOSAL PONDS ❑ I hereby cenify 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicani must call for all required inspect ions. Complete orgviing n_psyerse side. r T/p Signed TD✓ Ltle: /•,C "� ,_. Date: b Vic) �n1 r ART E ONLY Application Accepted by /� Date Ar -��> Pit or Grout Inspection by Datet% _ G Final Inspection by Data e'— .L.LU Additional Comments: Applicant - Return all copies to: Sm Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazeltoo Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED_ 17110 /CASH RECEIVED BY DALE/y`� PERMIT'N�0/. . c€H 1s7sWlayEv.t/net ✓ J Ov /1 10