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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 O BOX 2009, STOCK ON, CA 95201 RERMIT EXPIRE$ 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sass Joaquin County for a permit to construct and/or install the work herein described. Thlu application Is made in coaspliance vith 'San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sar. Joaquin County Public Health Services.. Job Address �7 3f,T� T A.i 11w,Al a✓ �� City�1�C� Lot Size/Acreage Owner's Name ._�FS S {6..Y1 �LeDuL Address r Cont+actor 1.1 L�rC1� Address RU. �,�� _ License No Phone j TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well L-1 � PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER 0 l+tonicoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL____ — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L f' 1-1 Industrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing _ 11 Domestic/Private ❑ Gravel Pack O Tracy Type of Casing- Specifications Il Public 1"1 Other n Delta Depth of Grout Seal _ Type of Grout I I Inipation __ Approx. Depth I I Eastern Surface Soul Installed by.—.-- Pepsi( Work Done U Type of Pump H.P. __ State Work Done Well Destruction O Well Diameter Sealing Material i Depth _ Depth _ _ Filler Material i Depth TYPE OF SEPTIty WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is r available wnhin 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of tivirtax units: Number of bedrooms Character of soil to a depth of 3 lest: c't- I.'g u 3t- --Water table depth SEFTIt~.TANK ❑ Typo/Mfg _ �.L L. Capacity�u4J�? No. Compartments __._.;z _�_� PKG. TREATMENT PLT.,Cl Method of Disposal Distance to nearest: Well 42y;-f� Foundation _.jra—� _ Property Line _c 1t 1__'` ✓` LEACHING LINE /'= ��} 7- r- --� '�', No. b Lengtfbp[y(ines Total length/sae •_i-___ FILTER BED n Distance to nearest: Well Foundation _ Property Line _ SEEPAGE PITS II Depth _�� T Size_._ � _ Number __ _ SUMPS. , Distance to nearest: Well_" Foundation,-.�J6L Property Line _ I DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and;regulations of the San-Joaquin County Home owner of licensed agent's signature certifies the following: "I certify that in the perlormanco of the work for which this permit is Issued, I shall not employ any person in such manner as to become subject to workman't compensation to-No of California." Contractor's hiring or sub-contracting signature certifies tbis following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to wizrkrnan's compensa tier:ilaws;of Celifornia." The applicant must call for all re jired inspections. Comptete,deawing on reverse side. Signed X Y Title; _g.4;-b; _ Date: — &U-F0LADI1,PARTMFN,T USE ONLX / Appiiut}qn Accepted by _ Date I ' Area Pit or Grout Inspection by Date ' Final Inspection byDate 4 +/ e I Additional Comments: Applicant - Return all eopioa to: San Joaquin County Public Health Services, Environmental Health Persalt/Services 1601 E. Hazelton Ave., P 0 Bo 2009, Stockton, CA 952()1 FEEAMOUNT DUE AMOUN7 REMITTED fk -' INFO CAS _ HECSIVSD BY DATE PERMIT NO. E„ ; 3-24 tNEV."A h 6! �.