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OK: APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIEALTH DIVISION 1601 E. HAZELTON AVE. , A�PHONE (209)468-3420 I t P O BOX 2009, STOCgTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate)11. Applicat on is hereby de to Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordlnattce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r S'! �21 Job Address (L—(!� 10 C-71\101Z-771- a '! City SZ71<41 Lot 51 ze/Acreage ' Owner's Name f'Got (�r�(?_mt! � Address I,t-LCLLyE L�[��^? S Phone 9C+8 ^ r v2 �^ may, r7 �j Contractor \' W Address�n0 L L l�-V T License No�v56J /J Phone rJ TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEMI REPAIR ❑ OTHER ❑ Monitoring Well U I _DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES IM DISPOSAL FLO. PROP. LINE y� FOUNDATION AGRICULTURE WELD. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom 6 Manteca Dia. of Weil Excavation Dia. of Well Casing [(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Ga'sing Specifications } I'? Public 1.1 Other n Delta Depth of G'rout Seal Type of Grout �lr 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done )(` Type of Pump t-1 H.P. T1 ( '� State Work Done _ i Well Destruction ❑ Well Diameter Sealing Material & Depth Depth'. } Filler Materiel& Depth c TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I i DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) t Installation will serve: 'Residence— Commercial_ Other .Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ------------ —Water r Water table depth ` 1 SEPTIC TANK O. Type/Mfg t t Capacity No. Compartments (� PKG. TREATMENT PLT. ❑ ' Method of Disposal h I r Distance tonearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines r- Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line yA IM SEEPAGE PITS 11 Depth Size 14 ' Number SUMPS LI Distance to nearest: Well Foundation.� Property Line DISPOSAL PONDS ❑ 11 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the-San Joaquin county IN 11 Home owner or licensed agent's signature certifies the following:g g g: "I 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." Contractor's hiring or sub-contracting signature certifies the following; "1 certify that in the performance of the work for which this hermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." l The applicant mus I for all re uirad inspections. C plate drawing on Signed X Title:._,/1,( Date: 'FOR DEPARTMENT USE ONLY Application Accepted by _-. 2-1 I` Date 7 �S Area 2 Pit or Grout Inspection by Data Jail by ! Date -'2L�/ Additional Comments; Applicant - Return all copies to: San Joaquin Couaty Public Health Services, Environmental Health Permit/Services 401 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE Ji. CK INFO AMOUNT/DnU/E♦ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. j EH 13-24 EH 71-�IREV.r/n5f 1C ��'�-/v (r� _ 7 •/