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APPLICATION FOR PERMIT i 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 Health Services. Job Address ✓ dt • City A44 M0+ Lot Size/Acreage Owner's Name ^'LA� 9 lL4-1 Address 1 7 T �• ut,�kCtJ ;2::p ANIcA Phone Contractor Address [_-8i_6 F-7 . #111)Z-rt'�6- 4r_( License No. Phon4.y _ fSL,( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public I 1 Other I� Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth - - ji__ (0 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic ystem permitted if public sewer is available within 200 feet.) G n Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms TAT 1�; .i�� L,(t-1 )/ t:A0i.TA-P,& 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 LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 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 county ordinances, 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 the work for which this permit 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 or sub-contracting signature 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 applican u t call for all r red inspec ions. Complete drawing on reverse side. Signed Title: 77Ez-/ Date: / ^/4- 9 ORDR E ONLY ' Application Accepted by ' -' DateArea Pit or Grout Inspection t Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PE IT NO. . EH A-2 (REV.rin5) /� ,UJ ! / / J✓ � EH .2e V C/ lJ 72i7 - 7-A Z7,D ;,