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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION .- 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 r PERMIT -EXPIRES T YEAR7FROM DATE I E) y (Complete in `Triplicate) Application 1e hereby made to San Joaquin County for a permit tb-conatruct and/or inetal11the work herein described. his application is made in compliance with Ban Joaquin County Ordinance No. 549,and"1662 and the Rules and Regulations of S an Joaquin County Public Health Services. Job Address CASr Oh oFvl-S 0.o /Nv27—/4 Or �T�� L, ` / /-a (- ,+ (�/�Fl .l Gty /Lot Size/Acreage OwnerL--s Name I' I if V j-. ��1Ut9 Address 6`lJ t7VXS ,��`,/�/� -L \ Wa .l Phone Contractor ZVOACl /(! 0 Address S F e6Mo/J /(� (-'�J f ' ppGG License No..S Phone Qd/7 TYPE OF WELL/PUMP: / 'NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out or Service Well ❑ PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well-' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHFR'WELL1 PITS/SUMPS C INTENDED USE TYPE OF WEL( PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndusVial ❑ 0 n Bottom .` Pa ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' O Domestic/Private ❑ Gravel Pack/ ❑ Tracy Type of Casing / I'I Public ❑ Other Specifications n Delta Depth of Grout Seal Type of Grout Xhri ation f p / - - 0 �Approz: Depth �SuHace"Senal-tn.1 1stalled by-- Repair y- --- --- - Repair Work Done U Type of Pump M/l4(/(/l,� H.P. J�o 11r State Work Done�L0.1 S'�- Well Destruction O; Well Diameter Seeling_Materialla.Depth _ 1�(_U yk ,C ! ueplh' Filler Material i Depth LA JG TYPE OF SEPTIC WOAK/ NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: -Residence_ Commercial_ Other' w. 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 10 PKG. TREATMENT PLT. ❑ m - - ' ' - - IY� 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 v i Property.Line SEEPAGE-PITS----N•-Depth_- _Size-_--=--'-e--=---_". ..= Number-- � SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El I 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: "1 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." Contractors hiring of sub-contracting signature certifies the following: "1 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 applican(t-mus call for all required�ctio�Complete drawing o(9-r/Aver side. ///� n Signed X— /.Fro C C(/7 Title: V!� 0 J� Date: (� ARTMENT USE ONLY Application Accepted byits Date Area Pk or Grout Inspection by Date Final Inspection by, lI"� 6—/.j�L Date (. Additional Comments: Applicant - Return all coples,to: Ban 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 INFO CA$N RECEIVED 8YDATE PERMIT'NO. EH;i.0 IREV. ,,,, ?NL'1 e,- 00 fi 1.,. . YIMI /. 1 1 n) n f 12-le.