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t r , APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL. HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 FffitYIT EXPIRES 1 YEAR FW9 DATE ISSUED %�90py I (Complete in Triplicate) Application is hereby made to Sew Joaquin County for a permit to Construct and/or install the work herein described. This ' application is made in compliance with San J uin county Ordinance No. 549 and 1$62 and the Rules and Regulations of Son Joaquin County Public Health Services. l , 'I Job Address City Lot Site/Acreage Owner's Name Address _ Phone Contractor_ (G�'t ----Address ? License No, f ��Z�e Phone � -M7 TYPE OF WELL/PUMP:Vk , NEW WELL El WELL REP CEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Monitoring well PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _x INTENDED USE �.TVPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 0 Industrial ` -,O.Open Bouam ❑ Manteca Dia. of Well Excavation Dia. of Wed Casing r E] Oomaslic/Private ❑ Gravel Pack• E7 Tracy. Type of Casing Specifications I-I Public I:1 Other ,.., _ n.Delta Depth of Grout Seal Type of Grout I I Irrigation —Approu. Debth~ I I Eastern Surface Saul Installed by Repair Work Dons Li -Type of Pump ^' H.P. State Work Done Well Destruction ❑ Well Diameter y_.,' Sealing Material i Depth i t Depth Filler )daterial ! Depth ' -- TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION I I DESTRUCTION l I INo septic system permilled it public wtwar is ___ .4— -—,.-available withiri 200 feet.I Installation will serve: Residence Commercial— Other '' _`"'!" Number of living units: _ Number of bedioom9 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Typs/Mfg Capacity No. Compartments �' f PKG. TREATMENT PLT.❑ � r Method of Disposal .440,62994- Distance to-nearest: Well 4Q Foundation 2 Property Llne .. ; ,.., b, .i ce LEACHING LINE 0 No. A Length of lines r Total length/site r FILTER (IE0 ❑ Distance to nearest- Well ,( '� Foundation_L� "' Property Liner SEEPAGE PITS I 1 Depth -size zr Number SUMPS LI Distance to nearest:- Well rFoundation Property Line DISPOSAL PONDS - -0 I hereby certify that I have piepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County t j Home owner or licensed agent's signature certifies the following: "1 cartify that in the performance of the work for which this permit is issued,I shall not i employ any person in such rttenrtar a$to become Subject to workman's compensation laws of California."Contractor's hiring or out)-contfacting signature certifies the following."t certify that in the performance of the.,wgrk for which this permit ii issued,I shall employ Manna subject to workman's compensa- tion lawsof-California." The applicant m %for all re a Insps 'ons. Complete drawing on reverse side. Signed x Title: A. Date: t•�..-•FGR-DEPARTMENT USE ONLY - i Application Accepted by Date pArea � 2 i or Grout Inapectbrt by , at Final inspection b � ii�G�^-«pate �z r i Additional Comments: i Applicant - Return all copies to: San-Joaquin County Public Health Services, Environmental Ree.lth Permit/Services Noe- 2601 E. Hazelton Ave.. P 0 Boz 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH Ka RECEIVED BY DATE PERMIT NO. 1 4'f A, `q . Httixatr1Ev.+ensr a0� to-C-12-31 EH to zs