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0 APPLICATION FOR PERMI0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMEI`IT. ENVIRONMENTAL HEALTH DIVISION RECEIVED 01 E. HAZELTON AVE. , PHONE (209)468-3420 O Folly P 0 BOR 2009, STOCKTON, CA 95201 jut,CoPERMIT EXPIRES 1 YEAR FROM DATE ISSU ENVIRONMENTALHEALTH (Complete in Triplicate) FFpp�fu�I77IISERVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work h?t'EYn dlscribed. 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 S/ervices.. Job Address le l6 ' rj. c4er�oyE-Qe t-!.A"^�C.. City I'd. -� Lot Size/Acreage w Z/V /� f� ,�1 Owner's Name C9"ekie- C:1 t Wa(N Address ��1/.�J� C-�Yn/!aP L i z- t Phone Po 6ox'726 .�-,�.z,J� y6- Contractor I Address LtnGolq ysby� License No.2y! L�Phone TYPE OF WELL/ UMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM RF,PAIR ❑ OTHER ❑ Monitoring Well 1v(' DISTANCE TO NEAREST: SEPTIC TANK &14- _ SEWER LINES #SY bO r DISPOSAL FLD._&14_ PROP. LINE-IL �C FOUNDATION Or AGRICULTURE WELL Mr- OTHER WELL Qa,Z- "VITS/SUMPS &A 177� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT NS Z rz ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation _ Dia. of Well Casing . '-�D �ciions 11 I') C�Gravel Pack ❑ Tracy/ ,,E/ Type of Casing ]pl/L SA_ S ficatej. r I'I Public Il Other n Delta`"e"^ IF Depth of Grout Seal G~roul I Irrigation '2112Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump ��._ H.P. i'�� State Work Done _ NA Well Destruction ❑ Well Diametm�a Sealing Material i Depth ' Well lh5'E' 1"oh Depth �.+.t Filler Material i Depth -IQ TYPE OF SEPTIC WORK: NEW INST=ALL.ATION I I REPAIR/ADDITION I I DESTRUCTION I I INo available w Ihln system permitted if public sewer is 6 Installation will some: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 subcontracting 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 compenea tion laws of California." The applicant must�ca�llll for all requlr d inspections. Dz"CxeQKwon reverse sid(((e. SignedTittle: 1pnq Date: 5 KyClJ. n-, +�+ 9ri IONnT re5� E ONLY I Application Accepted by Date res , 7 Pit or Grout Inspection b Datenspection Date _ Z-- 6 Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE DUE AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERM17N0. INFO Q . EH 13-24 IREV.i/x5r 3s �� t� �/ (✓ 7`��J '3]/ NFO EH 1620