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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 O BOR 2009, STOCKTON, CA 95201 D PFJWIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein describ-d. V,1 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. �� Job Address 35100 4'36Wa�_ City_1LwC1 ,5 __ Lot Size/Acreage (�O_ X Y60 _ Owner's Name 1L1IZAgrn �;Nm Address �aSCi�c��C r�IeTS�� yS Waj&AC(Mk C.H Phone #�LYQ -93.�J _ I?g5,gF Contractor 5E Address 2SW0/d CrowCanynaR& 5ci.,&m�onLicense No. ggID00 Phone(r(/S 820 g5(� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION n Out of Service Well f l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ CS011 1!l°1IV_)OTHER LR' Monitoring Well 1� 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 I 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private Cl Gravel Pack Il Tracy Type of Casing-.. Specifications._- I I Public 11 Other 1-1 Delta Depth of Grout Seal __ Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth S t-we a <e-A%riA W Depth Filler Material ti Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic systern 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 _ Capacity__ No. Compartments _-_._-_. PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well _ Foundation _ Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED 1.1 Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 subcontracting signanne 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 Jnspections. Complete drawing on reverse side. G/ Signed X — Title: �t f �-�-��(D�v — Date: J/$1"90- FO EPAR M T USE ONLY Application Accepted by zZ- ?0 Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK 0 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO L, �j rrr ,ta,(REV ,,Ner 31S- 4 LM � / 31ZU7 'a -Z-fe-) n