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• APPLICATION FOR PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL ALTH DIVISION 1601 E. HAZELTON AVE.�PHONE (209)468-3420 ' � In l ►' �� P 0 BOR 2009, ST&KTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I S Ep j Application is hereby made (Complete In Triplicate) to San Joaquin County for a permit to construct and/or install the VOIA1�[�[i.+�?.��(f�r�;;e 1� application 1s made in compliance vith Ban Joaquin County Ordinance No. SL9 and 1862 and the RuieePkkrd✓�� tl This Joaquin County Public Health 9ervicee. n of San Job Address 1 95r1 F Lathrop A City i.a th-_ rn Lot Size/Acreage 10 ar• Owner's Name Pat and Cheryl Mitchell Address _P.O. ROx 1219 T th O Phone Contractor Osterberg 6 Stewartgddress 2523 River Rd. Modest TYPE OF WELL/PUMP: NEW WELL �'—'��cense No. 996670 Phone 209 537-576 T� WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 7 SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK '�! OTHER ❑ Monitoring Well -f�-L SEWER LINES I/�R__ DISPOSAL FLO. M _ PROP. LINE025'0' 3W� 6�e FOUNDATION LS/ AGRICULTURE WELL IWO OTHER WELL .1n INTENDED USE -[� PITS/SUMPS�✓,� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation_LQ Dia. Well Casing Domestic Private Gravel Pack L7 Tracy T of I'I Public 1l Other (1 Delta Type of Casing P✓__C Specifications..-- I Depth of Grout Seal I Irrigation --7—L— Type of Repair Work Grou(itLr (rt MF a�Approx. Depth i I Eastern Surface Saul Installed b Done ❑ Type of Pump y--gr�f��'{��'" '�"-�£lA1CL—r"' Well Destruction H.P. State Work Done_ O Well Diameter Sealing Materiel L Depth DepthFiller Material i Depth \ TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is Installation will some: Residence_ Commercial available within 200 feet.) }� 1 Number of livingunits: _ Other 1�1 Number of bedrooms Character of Will to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg Water table depth (� PKG. TREATMENT PLT. ❑ Capacity No. Compartments '\ Distance to nearest: WellMethod of Disposal J1 Foundation Property Line LEACHING LINE Ll No. & Length of lines FILTER BEDCI Distance to nearest: Wall Total length/size Foundation Property Line SEEPAGE PITS 11 Depth Sire SUMPS LI Distance to nearest: W --' Number ell ry DISPOSAL PONDS ❑ Foundation Property Line I hereby certify that I have prepared this application and that the work will be done in acc rules and regulations of the Sen Joaquin County ordance with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following: "I certify that in the employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Performance of the work for which this permit is issued, 1 shall not certifies the following: "I certify that in the performance of the work for which This permit is issued, 1 shall employ tion laws of California." p Y peroons subject to workman's compensa- The applicant m for!Ira re rqd i ions. Complete drawing on reverse side. Signed X ! rJJ 1 Title: , Date: Q FOR D RTM T SE ONLY Application Accepted by Z G C Date ✓�(� Area Pit or Grout Inspection by G Date �Z/ vFinal Inspection by Additional Comments: Date 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 INFO AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO. . EK IlN INE%.v s 11