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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMEN 1601 E aAZELTI ENVIRONMENTAL AVE. , PHONE (209)468-3420 01't_D P 0 BOX 2009, STOCKTON, CA 95201 AUG 2 'l.9' PERMIT EXPIRM t YEAR FROM DATE TsSU f1 SA.1I jOAQUTA CCUn)TY PUSUC H (Complete in Triplicate) >,, : EALTH S 3V:CE ✓ rtC17JivIENTAL Hr`rH . ; Application Se hereby made to Sea Joaquin County for a in '• application Se made in c mtpllance with San Joaquin County Ordinance No. 549aando1862sand the tall eRules and work eRegulations of Sans Joaquin County Public Health Services. Job Address R En / OKEL UM N -TtCFF/T cjty NLr.71 CUL�S1ze/IAcreage Owne's Name C&-1EZ)P' jA _(LL Address Q r� '45ac7 �9��1 Contractor Bi i� ILI.II�(f Address C Ir Le License No. S� �I� Phone & Ny TYPE OF WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 .3 Monitoring We115 'iy DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 7t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation /C " Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing FVC 5eh 4 1 Specifications I'I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Dane `U/ Type of Pump H.P. State Work Done_ /j.,lil C4- 61�, Well Destruction %1 Well Diameter rr Sealing Material i Depth A;=On� 3 Depth N(o,: Filler Material i Depth 4o `f 6•�r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is ( available within 200 feet.l V� Installation will serve: Residence_ Commercial_ Other �� Number of living units: _ Number of bedrooms //1� Character of wil toa depth of 3 teat: _- �( �� .V�J ter table depth SEPTIC TANK 0 Type/Mfg C „m, Compartments ` PKG. TREATMENT PLT. ❑ �� ]` Method of Disposal Distance to nearest: Well Foundation property Line LEACHING LINE Ll No. 6 Length of lines Total length/size A FILTER BED ❑ Distance to nearest: Well Foundation Property Line F� SEEPAGE PITS 11 Depth Sire Number 3 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F I hereby cavity that I have prepared this application and that the work will be done in accordance with San Joaquin cc as, state laws, and rules and regulations of the San Joaquin county Home owner or licenaad agent's signature canities the following: "I certify that in the performance of the w issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Californl ub•contracting signature certifies the following; "1 certify that in the performance of the work for which this permit is issu fact to workman's compensa- tion laws of California." The soPitun/y(�nust ca fff all requbed inspections. Complete drawing oonn reverse side. p Signed X /J r / �, /L< Title: v_-� Data: 7 F EPART T USE ONLY Application Accepted by �7 q gggg Dat L— !/ Area / Pit or Grout Inspection by Date Final Inspection by I Oats ) I Additional Comments: SGtvifl Cr'C) r lWI Br`ri5'fKS f ApPllcsat - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services �D C 1601 E. Raxelton Ave., P 0 Box 2009, Stockton, CA 95201 -J INFO FEE AMOUNT DUE AMOUNT R /EMITTED CK CASHc, RECEIVED BY DATE /` PERITN0 M .'T - En 14.26(REV i,.,i [O �ZZ b �'-jz %/ g/_ZEN EN t _m