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APPLICATION FOR PERMI'D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION . " 1601 E. HAZELTON AVE. , FRONE (209)5468-3420 P O BOX 2009, STOC TON, CA 95201 EXPIRES 1 YEAR FROM DA'I'S ISSUED (Complete in T iplicate) Application is hereby made to San Joaquin County for a permit to coristruct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 5>t9 and 1562 and the Rules and Aegulatiens of $an Joaquin County Public Health Services. it ! Lot Site/Acreage Joh Address Y ---- - L /l �� 60 oe Phone G� Owner's Name �u1��5�L t �I�GO Address Contiactof V4Am < 111 Address IPPAer / ! License No. Phone Ile 34ZliAve' TYPE OF WELL/PUMP: NEW WELL 10 M(V--r WELL REPLAC MENT Cl DESTRUCTION Cl Out of Service Well PUMP INSTALLATION ] SYSTEM AEPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK >LOW SEWER LINES -2lY'!t DISPOSAL FLD. T� PROP. LINE -� FOUNDATIONAL AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS rt f_l Industriai 0 Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing G� ( i Domestic/Private )W Gravel Pack le Tracy Type of Ca ing P Specifications P4 Public J ctr�or Cl Other Fl Delta Depth of Grout Seal Type of Grout I I Irritlation .. — Approx. Depth I I Eastern Surface Set I Installed by Repair Work Done L7 Type of Pump H.P. State W rk Oo a _ Well Destruction ❑ Well Diameter Sealing Material Depth r Cry C Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I D STRUCTION I I INo septic system permitted if public sewer is available within 200 feet.i 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 0 Type/Mfg Cap city No. Compartments PKG. TREATMENT PLT. f_l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FiLTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D i hereby certify that I have prepared this application and that the work will be donE in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin County Home owner of 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 Calilornis." 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 f r all required inspections. Complete drawing on reverse side, f Signed Title: AWJllkke,,14 �� -+Zz Date: FOR DEPARTMENT USE ONLY Application Accepted by (21 • Date _ LvY3� 13 9 Area Pit or ro Inspection by Date 4`2-0-` 0 Final Inspection by � � Date_!;LZ ' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH -4-M