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APPLICATION FCR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 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 PublicHealth Services. Job Address —1"1000 F. Idsn �'IL OF Pil City 04 MIr '�S Lot Size/Acreage --I l.J Owner's Name b, [L`14I �4\.i �fl' Address i �, �' A6'!2 0 �y `�.mT41�j Phone '� 137 Conlractor Address _�? -y-�, tT7'I 'xF'l IS'%"Z-Phone %Y TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ -- — - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring C3� g Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL �lW 1 D. 07- PROP. LINE IC r FOUNDATION O+ AGRICULTURE WELL — OTHER WELL— = PITS/SUMPS 150 Y L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U - S/b ❑ Industrial )ZOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,KOomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S--Zz-Q Specifications • 1Sx 1'1 Public ('I Other FI Delta Depth of Grow Seal SC , Type of Grout qSW= 6. I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by — Repair Work Done ❑ Type of Pum H.P. i State Work Dona _ Well Destruction ❑ Well Di star Sealing MateriaYl�L/D�ptt� V Dept Filler Maters D pth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is .� available within 200 feet.) Installation will some: Residence_ Commercial_ Other t\ Number of living units: _ Number of bedrooms Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near Well Foundation Property Line i LEACHING LINES, ❑ No. 8 Le th of lines Total length/size r FILTER BED ❑ Dista a to nearest. ;Yr Well Foundation Property Lina � N SEEPAGE PITS I 1 spin Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin countyrdinances, state laws, and M 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 ermit 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 osub-contracting signature certifies the following: '9 certify that in the performance of thaVork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California •' The applicant mus gwre in pe Complete Arawing on reverse side / R p Signed X r / DEPARTMENT USE ONLY Ap � anon Accepted by r Date ti ri_x.. V Area LPit Grou Inspection by Date Gr. . . dFinal Inspection by Date6' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health � Services, Environmental Health Permit/Services \x t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DDE AMOUNT REMITTED CASH I R[�E�I}I:EEIIIVVVED By �n DATE q PJERMI7/�N-O-f. Em i4al EV.vn3i MM.0 � .1.__ _ JV—lU-ZO Ctfl —eel/ Ea 1414 __ - _ _._ - — —_