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APPLICATIONAOR PERMIT S + Q S {{` SAN JOAQUIN COUNTY PUBLIC HEALTH SBTcVICES ��'� l ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 II P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , Application is hereby made to ban 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 ,7,7✓.J k/r [�4�Yt IVf?✓ LC-7rrP City 5;4e1&A,1f Lot Size/Acreage 5/D Owner's Name Dftl lY S MG✓KG l Address P./� /;cX .S(7 L/SIr ��,�„ ,� phone �SL� Contractor Pefdk /�u[1Y/It' T Address '925'0 %�6«i P/ hYf1NNr License No.62L930 Ph on TYPE OF WELL/PUMP: .NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out ice Nell 0PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 ring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE SV�Oty FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public Cl Other (l Delta Depth of Grout Seal Type of Grout 11 Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth �. Depth Filler Material i Depth M1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system itted permif public sewer is available within 200 feet.) ��VVVvlll Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK- 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line PAYMENT LEACHING LINE 0 No. i Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Lined [� I IHIC G U I.ny,J� C_ • SEEPAGE PITS 11 Depth Size NumberC,�pANT Inane Ilnnl l rnnTY SUMPS LI Distance to nearest: Well Foundation PropefQQR61C HEALTH;iERVICES DISPOSAL PONDS O ENVIRONMENTAL HEALTH DIVISION 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 1 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 subcontracting 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 applicant ust call f all fy fired inspecntions. Complete drawing on reverse side. Signed / /!P_014 4101 Title: Se'H/Cd P% tc4 bt �dsrr� Date:A&, FOR DEPARTMENT USE ONLY � I Application Accepted by Date 3 31 Z II G Pit or Grout Inspection byFinal Inspection by Date�- y 7_21- Additional Comments: . I Applicant - Return all copies to: San Joaquin County Public Health 'f L_ Services, Environmental Health Permit/Services +] 1601 E. Hazelton Ave., P 0 Box 2 tockton, CA 95201 I FEE gMOUNT DUE AMOUNT flEMITTED CASH EIV CK 0 BY DATE PERMIT' INFO MO �a11 ��j'��n D �a �y'}� J . EHI}2�IaEV.rrnel �•� �-o-c.) V (/4WD 3(3� -I�' 2. _✓.5 't EM M24 V I