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��Ir♦1� APPLICATION FOR PERMIT N"101 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��jTo (Complete in Triplicate) A<C 'kTTF X42 Application is hereby made,to San Joaquin County for a permit to construct and/or install the work here '��ccFi d This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regttt�oF�t�San Joaquin County Public Health Services. Job Address rUo3 IE .�r d r r_S Ay L/ - _ City �rye-%Cro^/ Lot Size/Acreage __. Owner's Nams_ � � ..t ` -�� --- Addre,r. �n�-K r� �" � �- ' `�"" � Phone 3663 O/l1�� iii,, Sri Tis & q14 Contractor RYF Off' l I tj G Gd • Address ctJO Gv c'po 0.4 License No. S-Z I Y it E Phone 6,Y/ TYPE OF WELL/PUMP: NEW WELL WO WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS / Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll DOMOMIC/Private Gravel Pack ❑ Tracy Type of Casing tfG Specifications 1p,l C �M1r r i— I'1 Public fa Other f-1 Delta Depth of Grout Seal -3 � ^�) Type o rout "x N I I Irrigation SLY 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 I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is available within 200 leet.l 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. & 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 csnify 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 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 must call)or all required inspections. Complete drawing on reverse side. �: Signed XTitle: L/; lit sc Date: ) Z- -90 {p FOR DEPARTMENT USE ONLY / Application Accepted by ° " C` Date / / ` 1 Area f L Pit or Grout Inspection by ?f��t,' f (� Date ? Final Inspection by +` ^-a / Date Additional Comments: Applicant — Return all copies to: Ban Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDJ CK RECEIVED BY DATE PERMITNO. INFO CASH . EH U-24 INEV.I/n e) EH 4-2a