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APPLICATION FOR PERUIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1501 E, HAZELTON AVE. , . PRONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1--YEAR FROM DATA .ISSUED ` (Complete in Triplicate) tApplication is hereby made,to San Joaquin County for a permit'to construct and/or install the work herein described. This applice,tion,la 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 City..4 t7ae;`� Lot Size/Acreage 4- Owner's -Owneis Name fkLipito t (-Address PIAX " 4 Phone t Contractor QEzaga!j Ir kri oa4r_-wrl_ Address_2525 a.. ;MYart a License No,Cjn�I.5l22-CA Phone ZQ34&& Z TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT © DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑. Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK t1A SEWER LINES ?59' DISPOSAL FLD. M4 PROP. LINE 2S FOUNDATION 1 20 AGRICULTURE WELL OTHER WELD 100 v PITS/SUMPS AA. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation..8 Dia. of Well Casing u n Domestic/Private ❑ Gravel Pack ZTracy Type of Casing F ASn ,PV{; Specifications SLk= AID Il Public n Other fl:Delta Depth of Grout Seal JA Type of Grout I I Irritation 2LL Approx. Depth I I Eastern Surface Seal Installed byS P. Repair Work Oana U Type of Pump H.P: State Work Dona_ Well Destruction ❑_ Well Diameter Sealing Material & Depth _ )c µoll(T V-4At1 Depth Filler. Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION- I I DESTRUCTION i I INo se uc system �� p y permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg ..Capacity No. Compartments C i PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. A Length of lines g Tota! length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS I 1" Depth Size Number SUMPS Cl 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 kensed 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 Calif or.nia," 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 taws of California." The applicant it tali for all required inspections. Complete drawing on reverse aide. Signed •-^ Title' GCVtt_. 1- q R_ Date LS-FE"Bec.A&f (992- FOR DEPARTMENT USE ONLY 1 Application Accepted by Date _ Area tA4J J�U � I Pit or Grout Inspection by Date Final Inspection by Dale(o% I' Additional Comments: 1 Applicant - Return all copies to: San Joaquin County Public Health Servicess Ztvironmeauil Health Permit/Services 1601 S. Hazelton,Ave....P O Box tocfctoo. CA 95201 XFOFEAMOUNT DUE AMOUNT REMITTED �CAS� I CEI BY DATE �PaERMtT N0. . EM 13-I4 IREV.t i Si �T, Vlra� •�� `-'i v/ 2I2'7 EM 74,211 44