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APPLICATION FOR PERM* Ca SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROTAL HEALTH DIVISION %rm PY, 601 p0 BOR 2009AVE. , PHONE STOCKTON, CA09501_��PERMIT EXPIRES 1 YEAR FROM DATE ISSUID 38s la (Complete in Triplicate) ��tA�11 ��• Application is hereby made.to San Joaquin County for a permit to construct and/or install th!` �e lEd. This application Se made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ru' egulations of San Joaquin C�ounty Public Health SSe/rpvi�cess.�� ,.,,//, t� Job Address — �t'XI.T� I.'VKj�yO eP— LQ,-.P,- ��' City ✓�'- a Lot �S1ize/Acreage q _33Y-45Z)6 Xz�tl Owner's Name `--Q� -;1 .S"W'&-�ddress'00% kvLa-r- . Lz 1' Phone 4/ 33Y 6s)6 Contractor f Address F_,.�coj qSt� 3 License No. 7 63'1 Phone _9 s TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI.ON ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES 12`120' DISPOSAL FLO. All PROP. LINE JE y MU Q FOUNDATION AGRICULTURE WELL 414-_ OTHER PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS et 0 Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing Z 1.1 Domestic/Private Gravel Pack ❑ Tracy , / Type of Casing Fv -CSpecifications `0 I') Public �l-ar�Other F1 Delta LRr Depth of Grout Seal •BL'l'oZyabpr.q�,�pa o f rout "E sE`� I I Irrigation aL.Approx. Depth AAI I Eastern Surface Seal Installed by OFlit'IVL .� �✓'", Repair Work Done U Type of Pump N!7 H.P. State W rk Done nrdQ- Well Destruction ' I ❑ Well Diameter-=;P11Sealing terial i Depth r t 5 I�'l67-4112f7 Depth " Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if 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 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t� SEEPAGE PITS I I Depth Size _ Number \ 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 `C rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "1 cenify that in the performance of the work for which this permit is issued, I shall not fy employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signature canities 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 applic t must call for all required i spections. Com ate dr�winppn reverse side. Signed x��(�- Q/brl�t -°� Tit Prodec+ 9eeloar ;Sfl- Date: Sj_ 32- �O FORDEP MEN NLY Application Accepted by — C Data_`' — � Are C c Pit or Grout Inspection by Date? ✓2 e9 Final Inspection by Date,Zf2—G'� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. NFO CABH . EH 13-24 IREV.1/n st3S �V ! !v /-1/ EH 14-26v f/O