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APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYM,Nlv- ENVIRONMENTAL HEALTH DIVISION CEI 1601 E. HAZELTON AVE. , PHONE (209)468-3420., P O BOX 2009, STOCKTON, CA 95201 AUG 2 1,01 ik PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUSS!!C HE L!�v CC'��rTY u� qL T H (Complete in Triplicate) E;'!V!R DNTALHEAL 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 cocpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health /p Health Services. /—DJob Address " O EL U/ / 6lE CT10EF-F City 4y �e /Mt�S,i ze/Acreage Owner's Name Address � l � ti� y' � ��KrQl)- CA Phone (Q� W5,)C7 Contractor ,J� ILL I/V(f AddressC License No. Sl Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 Monitoring Wel1S 'iy DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /r 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /C Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing IyG =CCN 'y 0 Specifications f'I Public Ll Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done �0 Type of Pump H.P. State Work Dane_ l r L(C t Gh L,' Well Destruction ;K! Well Diameter Sealing Material b Depth �M-an:L 3 �, Qy / \ Depth '76, Filler Material b Depth 4�0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is f available within 200 feet.) �1nnn� Installation will serve: Residence _ Commercial— Other ly Number of living units: Number of bedrooms D \ Character of soil to a depth of 3 feet: ter table depth SEPTIC TANK ❑ Type/Mfg C . Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ P 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin co _ : 5es, state laws, and 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 thew r .n. slued, I shall not rbr ,x employ any person in such manner as to become subject to workman's compensation laws of California ub contracting signature certifies the following: -I certify that in the performance of the work for which this permit is issue s e �+ fact to workman's compensa- tion laws of California." The appiican ust call f all required inspections. Complete drawing on reverse side. ��$ Signed Title: v Date: _l — S / FEPART T USE ONLY �� ?�5i /G Application Accepted by Dat. i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 01 LC f'cD Applicant - Return all copies to: San Joaquin County Public Health Services, Eavironmental Health Permit/Services CG�� 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH Kit RECEIVED By / DATE PERMIT NO. E 13.21 IREV.ti■si ENH 74-2a O