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�v-2zo/S2- Coo APPLICATION FOR PERMIT ./ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342U P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sm 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. Soo//•sir T741Q / Job Address _ / OA City I"Ac7Krf GwL Lot Size/Acreage Owner's Name��svJ;42mr.v 6yu. ry Address 600 ry1AvsFv',Cce+G28 Phone or %8-2180 Contractor u Address 28-Ir . &4m mc V License No. S/Z?(s$ phone !L TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION )C Out of Service Well 9f 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 PROBLEMAREA CONSTRUCTION SPECIFICATIONS ❑ Industrial "Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'1 Public 1-1 Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction Ip Well Diameter N%Xylilwat, Sealing Material a Depth xr%AA Depth /9 G Ff`rT Filler Material L Depth CS TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of Will 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 ❑ 1 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 persona subject to workman's compansa- tion laws of California." The appli ant m t call for all required ins tions. Complete drawing on reverse side. /� pts 921 Signed X h' Title: ��lo f scTya-OG o 4tS f Date: FOR DEPARTMENT USE ONLY Application Accepted by Date a Pit or Grout Inspection by �t Date D 1 ! Final Inspection by a 5�{ ka0 Ss.-d VCR ..+... p Additional Comments: -f'��i%'�°'Ak —Iger 159J I�vna (4 Applicant - Return all copies to: San Joaquin County Public Health j Services, Envlronmental Health Permit/Services TCI- .2 (JyyE� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, C 95201 FEE INFO AMOUNT DUE AMOUNT REMIT-TED CASH /RECEIVED BY DATEE�; PERMIT NO, . EH 1124 REV.i,tsi �'� /VD 5 ✓ l//�� I EN 4A