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- APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES: ENVIRONMENTAL HEALTH DIVISION � r 1601 E. HAZELTON AVE: , PHONE (209)468-3420 P O BOR' 2009, STOCETON, CA"9520] N O V 7 1`�0 PER1lIT EXPIRES ]. YEAR FROM DATE IS =NVIROPJMENTAL HEALTI"i SUED,,, (Complete in Triplicate) ERMIT/SERVICES 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 vith San Joaquin County Ordinance No. 549 and 1862 and the .Rules and Regulations of San Joaquin County Public Health Services. Job Address om sl=nCity Lot Size/Acreage ±3 2(P Z9O .5 [i( 11m Owner's Name QMJ14089AUf rieA Y1 Gds Address Phone —� Aor Ban Ap%� 91L 373. 1!S Contractor 1IJi5- 5Tr Address License No.5!j:212 _ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Z1 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTTHEERR ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7�� SEWER LINES �Dr DISPOSAL FLC;2! PROP. LINE W 2, FOUNDATION D� AGRICULTURE WI LLZ` D OTHER WELL�� PITS/SUMPS 7�SG INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation /O 77 __ Dia. of Well Casing Cl Domestic/Private Gravel Pack ❑ Tracy Type of Casing 1/ Jove, Specifications 1'1 Public �C1 Other 171 Delta Depth of Grout Seal P14 ype of Grout5a" ' wE S1U I i Irrigation +�.Z Apprax. Depth I I Eastern Surface Saul Installed by Repair Work Done U Type of Pump NIA` - WP. State Work Done Well Destruction C1 Well Diameter Sealing Material A Depth a7— +�'�01 b 1 L4. moA r6r'f t Depth Filler Material 6 pepth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I 1 D ROCTION 1-1 INo m st m mitted if public sewer is available within 200 ffeeetJ Installation will serve: Residence— Commercial_ Other �j�qS¢- $ems R 11etLL LC, � tjo r — k Number of living units: Number of bedrooms P1 ow, + L'iQa Cp r%,-+. r�jQ� YZt"-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 0 No. & Length of lines Totat'length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS 11 Depth Size Number (�j SUMPS Ul 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 certifies the following: "I certify that lin 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 signatu:a 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 re uir inspections. Complete drawing on reverse side. Signed Title: %ea;a a Date: VV C1 i,Ja,I facer—k�t�R.� .sem FOR D ART*EDIT USE ONLY f Application Accepted by l Dace ZZ 40Area r Pit or Grout Inspection by DateFinal Inspection b Date Additional Comments: / Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATE PERMIT'NO. . EH 14.211 IFEV.mrMs1 e', 1`1 �/ 'eQ EH :1.2e ' J