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r I_} APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 PAYMENT P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED PERMITXPI ES I YEAR FpiOidc AIEte) ISSUED MAY 0 9 09--49,9 (ComSAN JOAQUIN COUNTY Application in hereby made.to San Joaquin County for a permit to construct and/or inai5er t 3. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 TAba4EAkhif)W%1M San Joaquin County Public Health Services. 1 Job Address 1140 \N . t4nr dt Irl VV o OSI. City ST1 JOGkfOV) Lot Size/Acreage 10��00 ff_`-, Owner's Name R•\#[` 1►eQ e Address 40k6lt Court ge-Al dl.bi U. 14705Phone 16-LA4_0(0* Contractor c#t ttm `X plp46njaAddress ZQ6 MWAf St !K—Ad_- License No. ,51ZZ(08 Phone H(15-U12- TYPE (15--U EZTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER Monitors W 11 �// �o�l.U�' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. INE 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 11 Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Specifications I"I Public 1-7 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _,_.. Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is U available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms I-, 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 BEC! ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 Horne 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 applicant m t call f r/a�lll required in ctions. Complete drawing on reverse side. Signed X_- C LS! Title: Eny-1 f S S?.d SOr_' Data: _M�iTL�1 youn gdak l �-A%oG a k is d�n C. DE ENT USE ONLY Application Accepted by Datt ` A Pit or Grout Inspection by Data Final inspection by Date��S_La Additional Comments: /7� f:vri 7�GiZ5 D C� ! 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT NO. + EM 13-24(REV.r�nsl �/ JJ J ;� - F j EH 14-28 f�c• CCZ//��'"` /