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f 4_� 1 APPLICATION POR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 eeri � d PERMIT ERPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to Sao 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 62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address d City Lot Size/Acreage if Owner's Name Address _ �/G- µ� l.� Phone Contractor Y C Address( T / /!4 S j61r_ License No. Y Q Phone W c TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR �k- OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications — III Public fa Other fl Delta Depth of Grout Seal Type of Grout I hrigadon —Approx. Depth 1 Eastern SFI ce Seal Instilled by I Repair Work Done Type of.Pump H.P. / State Work Done Well Destruction ❑ Well Diameter ,Sealing Materiel 8 Depth Depth - Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: _ Number of bedrooms I 1 Character of wil to a depth of 3 feet: Water table depth ` SEPTIC TANK- ❑ Type/Mfg Capacity No. Compamnents r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines _ - Total length/size FILTER BED Cl Distance to nearest' !Well Foundation Property Line SEEPAGE PITS 11 Depth v- Size I I Number SUMPS l ,- ' - LI Distance to nearest: ' Well - Foundation Property Litre DISPOSAL-PONDS- j ❑ �. 1 hereby certify that 1 fieve prepared this application and that the work.will bedonein accordance with San Joaquin eo`udty-ordinances, state laws, and rules and regulations of the San Joaquin County - Home owner or licensed agent's signature canities the following: "I certify that in the performance;rthe work for which this permit is issued, I shall not employ any person in stxh manner as.to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that Ih the Performance of the work for which this permit is issued, 1 shall employ persons subject to workmanZom nca- tion awe o kflornla." {.+�. _� , The leant m 8t call for-all re 'd in ions. Complete drawing on rev ads. Signed \',�� Title: �j0 ' ZQ/ •fir r ,--7 Date: 1 -. DEPART 7-USE ONLY y L._._S Application Accepted by t./S1t('w�. V, Date ��4 1-�l Area t_ Pit or Grout Impaction by Date Final Impaction Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Bivironment.al Health Permit/Services 1601 E. Hazelton Ave., P 0 Hoz 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED SV DATE PERMIT NO. EH I2 INFO CASH y�� /� 4 ` ` EH 1/.24 IREV.heal �� --- Q.�'1.Grt t r P_ t i •.,1`'. 1 I�)IT