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APPLICATION F01t PERM Z Tn SAN JOAQUIN COUNTY PUBLIC HEALTH -SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , P ONE (209)468-3420 P O BOX 2009, STOCK ON, CA 95201. EXPIRES- 1-YEAR F FROM DATE JSaUED (Complete in Triplicate) L! Application is hereby made to San Joaquin County for a permit to Con truct and/or install the work herein described. Thic application is made in compliance with San Joaquin County Ordinance o. 51+9 and.1862 and the Riles and Regulations of Sssn Joaquin County Public Health Services. Job Address �6. � e" P101,17 S '� �� City/rQ�_ Lot Size/Acreage Owner's Name Phonon�T� 3 0 `�7 /401 Ida y l�rn 7 _ / Contractor /! �° �' dress C 1 c License No. 11/ Phone�I�' 7G 4 Tl'C7 TYPE OF WELL/PUMP: NEW WELL ifs/W-6 WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well I-) PUMP INSTALLATION JD SYSTEM PAIR C1 OTHER [) Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK> IF SEWER LINES 2O t DISPOSAL FLD, PROP. LINE _ ..., FOUNDATION __A0_ AGRICULTURE WEL1T IL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC AON SPECIFICATIONS Fndnstri l' U Open Bottom D Manteca pia. of Well Excavation_ Dia. of Well Casing f I Domestic/Private04 1 4, Gravel Pack Tracy Type of Caii.ii ig �j�. 1"et,T__- Specifications ►id Public nlo+u>+vr , I.1 0 her 1-1 Delta Depth of Gr ut Seal Type of Grout r}!K c f I I Initlation Q.Approx. Depth I I Eastern Surface Soil Installed by -- .Repair Work Done 0 Type of Pump _ H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth / ,s, , Depth Filler Material &':Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITtON I i DE TRUCTION t I (No 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 soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Cana ity_ No.'Compartments _ PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines _ Tota! length/size- FILTER BED CI Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS 11 Depth Size _ _ Number SUMPS 1-1 Distance to nearest: Well Foundation _-_ Property Line DISPOSAL PONDS ❑ 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 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 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 pe mit is issued, I shall employ persons subject to workman's Compensa- tion laws of California." r, The applicant,must call all required inspections. Complete drawing on reverse Si I e.�/� g Signed X. _ _L �Yl6V�iG��✓ Title: /GCr1L+ +E/_ 'i��" '1 Woe Date: FOR DEPARTMENT LISE ONLY Application Accepted by Dated 1 Z__7_ Area a- T� Pit o hir ut spectlon by / Date fn•ZO' Final Inspection by_�. Date Aao-_KD 6 Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Ilealth Services, Ibvironmental. Health re mit/Services 1601 E. Hazelton Ave., P 0 ox 20 9, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO, INFO CASH I: . tr1rt2ttnEV.v,Msi 3.�