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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Cpm-Co(,,aJJ- E.,�erpris�5 -u�es'- Job Address[100 /lfi�ii"1 '�SOri City �Q °n� Lot/Jsize/Acreage Owner's Name �in�Pr�A�O� Ewlx ptlStS -L✓4'Address l�b� r'rliex5 B�vc� div► L�+1��01 hone fs �7��i300 r �, 10 111 n Ave.. 144 7 0 � Contractor W ^� t Address License No. �oO71 9 Phone z� go3'777 TYPE OF WELL./PUMP: NEW WELL Va% oP WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well PUMP INSTALLATION ❑ '�j Ocj � SYSTEM REPAIR ❑ OTHER C3r L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 4�/ PITS/SUMPS _ / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .0 r r�-,��, -r Industrial O Open Bottom C1 Manteca Dia. of Well Excavation /U ' Dia. of Well Casing =h''"—ll.nDomestic/Private �d Gravel Pack ❑ Tracy Type of Casing=4 y� VG Specifications �) I"1 Public Cl Other F1 Delta Depth of Grout Seal D--h LO-Al.of Grout H ee+n n 1 nar 1 1 Irngation 3 4Vg6'j! 'b Approx. Depth ( I Eastern Surface Seal Installed by k rah 5n✓+r D � Repair Work Done U Type of Pump H.P. 4J.- J LG State Work Done .N.4'• lJ - Lf'z Sealing Material & Depth��}onl>R< �-6�. �¢^�� ,�/�`f/ , Well Destruction ❑ Well Diameter �� (y5-(oa) Depth 3 k q,5�l f. 68� Filler Material & Depth#2 /►btik_ e~e TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I 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 bedroo Character of soil to a depth of 3 feet: 794^ Water table depth SEPTIC TANK ❑ Type/Mfg JA U C city No. Compartments PKG. TREATMENT PLT.❑ Illimf 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 It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 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 for all required inspections. Complete drawing on reverse side. / Signed X Title: 1 -S Date: l� _C_ FOR DEPARTMENT USE ONLY !' Application Accepted by ^ Date Area Pit or Grout inspection by �� -+"-- Date Final Inspection by Date—/,///_'IA � —LA IA Comments: �Jp LLL'iLS Dom( 1 L;Ial hiL r"Z aAIC2S I Z Applicant - Return all copies to: San Joaquin County Public Health /) Services, Environmental Health Permit/Services �`� 1 111 1601 E. Hazelton Ave., P 0 Box 2009 Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK x ECEIVED BY DATE PERMIT'NO. INFO CASH . EM 13-24(NEV-tix sr4►% .(� rW ��`�� 1 �• �•�� `�� . EHA-26