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f �t . � APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES: ENVIRONMENTAL HEALTH DIVISION - r• � �� !'t'1;i.' 1601 E. HAZELTON AVE. , PHONE (209)468-3426 Z 7 C E I 11IE r_'. P O BOR 2009, STOCKTON, CA-95201 1I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- ) (Complete in Triplicate) �I ;""',ZONMENT_9, Application is hereby made.to San Joaquin County for a permit to construct and/or install the work het.+ gdeFgx.be� '1'1'fr, application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Ij Job Address 200 0,1 #w /)-cr f O C,Al'e, City Lot Si Ize/Acreage Owner's Name `rte.-�l� IJ:�C r{� Address 6 C, LK 6 fZe4en 7S3C 1 - Phone( Contractors �c rc.� if- ,�-, Address en - � License No. IIA2��Phon yes-V71 C TYPE OF WELL/PUMP; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Kell ❑- C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. t PROP. LINE C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t .2 n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ S Dia. of Well Casing f:1 Domestic/Private Gravel Pack ❑ Tracy Type of Casing G t Specifications i'1 Public fa Other (l Delta Depth of Grout Seal 3 b i Type of Grout t I Iffigation Approx. Depth K Eastern Surface Seal Installed by` Tl, �^ Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ,111Q -t CO— e_Y-L Depth Filler Material i Depth (fir TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is l available within 200 feet.) Q Installation will serve: Residence_,.,._ Commercial_ Other ?f Number of living units: Number of bedrooms Character of loll to a depth of 3 feet: Water table depth IF SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method Iof Disposal a Oistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Lined I I SEEPAGE PITS 11 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby cartify 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 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 must call for all required inspections. Complete drawing on reverse side. Signed X yk rIA Title: 249 �1:..� -�tr�I�Y" .. Data: . slxalg� "J FOR EPARTfV1ENT USE ONLY / �'/ 9� `r Application Accepted by Date Area I 1G�,� Pit or Grout Inspection by ate g 9 Final Inspection b- ! vw `a -- Date Additional Comments: + 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 AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY PATE ' PERMIT'NO. INFO a . Em 13-24(REV.,,R s, EN:x•26 i�