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r APPLICATION FOR PERMIT SAKI JOAQUIN COUNTY PUBLIC HEALTH S, RVICES TH II ENVIRONMENTAL HEALDI1 §I9 1601 E. HAZELTON AVE. , PHONE (209)468-3420 f P O $O% 2009, STOC%TON, CA 95201 " XEHMIT MIRES T Y AR FROM DATR Tj%= f (Complete in Triplicate) Appllcetieri Ss'Density mede'to Ben Joaquin County for s portal to construct and/or ial ll the vark herein described. This application is made in eoamllenca with Sea Joaquin County Ordinance Ho. 549 and 3.862 end the Rules spit Regulation, of San ` Joaquin County Public Health Services. Job Address h1QU+&ih tiff t tk. City O S^T✓QG Lot-Size/Acreage 35Moxl Owner's Name--ViiI COMliv il.C+l - .Address 3l 7YdI Phan. 03(o-1560 lIJ' 0914 Contractor Waf� ✓r 1C Address rfl•�DX License No:=�ti 2�Ptfone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Hell ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ 6Yaa+04 SI OTHER L� Manitaring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - D Indusidal ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing i ❑ Domestic/Ptive to O Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H . State Work Done_ Wall Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation wNl aerva: Residence— Commercial— Other available Within 100 feat.) Number of living units: _ Number of bedrooms Character of soil to a depth of 3 test: SEPTIC TANK. ❑ Water table depth TypelMfg CsPacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal , Distance to neereat: Well Foundation Property Lina LEACHING LINE ❑ No. d Length of lines Tonal lang[h/ai:a FILTER HED ❑ Distance to nearest: Well Foundation Property Lim I i SEEPAGE PITS 1 I Depth -Sill Number {I! SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances• state laws, ander rules and regulations of the San Joaquin County Homs owner or licensed agent's signature cenifiee the following:'9 comity 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 all to workmen s compensation laws of California."Contractors hiring or subtroo tracing 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 temporise. tan laws of California." The applicn mf call fold d inspections. Complete drawing on reverse title. Signed Title: ��.N..a.-..`3 R"'a�)Date: j FOR DEPARTMENT USE ONLY p / 21.E Application Accepted by Date ^70 nee Pit or Grout Iropection by ate Final Inspecbon y Date Additional Commema: f y Applicant - Return all copies tot San Jonq a County Public Health�{' I'kYA�IQ `1Y/ ver4 /' e {G Services, P.avirot�ental Health Pa t Services 111 ! r O 1601 E. Haseltom Ave., P 0 Boz 2009, Stockton, CA 95201 EEE AMOUNT DUE AMOUNT REMITTED INEO C RECEIVED 9 i DATE PERMIT'NO. • Ea 13-24 IRII .ti ly 1 <� FN:aai