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�4110.0 APPLICATION FOR PERMIT `^ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealthServices. �j /J Job Address j uba I Uo(7L / c si 7o/ CityAe-4-1 Lot Size/Acreage /5"ee Pr 5. Owners Name )m g j((�[ EL Ad ice�.Addressq� I r�L'�7ca A.1�Yt Lzs c751 �f q Phone Contracts / I Address P D *&"j- 4 2- ('b Z V License NoI2 f�� Phone z 1 TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION', SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK /DD y SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/� INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT)ONS D Industrial 'Open Bottom ❑ Manteca Dia. of Well Excavat n Dia. of Well Casing `'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing C'�e'� Specifications I'1 Public 3�Ih'r fl Delta Depth of Grout Seal -I--�' Ty of Grout Z 1 eh I I Irrigation pP- E)Approx. Dept I I!Easkern uAace Seal Installed by (�C� �/ 1�� 7 h er mp CJ Repair Work Done ❑ Type of Pu � .f(1 H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth 4 TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line - - ti LEACHING LINE ❑ No. 8 Length of lines Total length/size v� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line (� DISPOSAL PONDS ❑ c, 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, ant rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not er employ any person in such mannas to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 1�1 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 compensa- tion laws of California." The applicant must call for all required 'nspections. Complete drawing on reverse side. Signed Title: Date: c t / FOA DEPARTMENT USE ONLY ��JJ ADplicat n Accepted by / Date 7 D Area 2-1 Ph or to Inspection by Date Y�1�inal Inspection by Date 2. 6�0 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services UCS 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO - MOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT NO. EH 13311REw.vxsi