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re c } APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is 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. /r Jr6w e Job Address Wei f/j4mmev L*oegq([ f(+ 3s07 dL• 116woke City 7 itIPA Lot Size/Acreage Owner's Name �r*'� 4"f J ��'� r09A Address 4,U_ l "��i-�a � — Phone O 11 37 i nn Contractor&fgtez L,/fr L'U Address #2f6I /�•x'ref 4x1`AfiwtLicense No. it .90 Phone - NO' LX TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ (( j G/D;rvvPW e,4ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 INo septic system permitted it public sewer is available within 200 feet.) 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. g 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 1 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 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 In all r i actions. Complete drawing on reverse side. Signed v D �Af�Title: °wiur /o c'[l, GAD�o IIT Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date •� �'�� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services,Environmental Health Pe t/Services 1601 E. Hazelton Ave., P 0 Box 2 9. Stcekton, CA 95201FEE INFO AMOUNT AMOUNT DUE AMODUNNTT REMITTED [LCASH ECEI ED BY DATE f /`PERMIYNO. . ER i}N IREV.irxsi Jt/ �.�(� Vr•OD W">—•!'7V 3 �J� T�i "{'(.^(� EM:47e