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APPLLCATI OSI FOR PERMIT 4 SAN JOAQUIN COUNTY PUBLIC- HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 1601 E-. .HAZFLTON_ AVE. PHONE (209)468-3420 cj 1j P O BOX 2009, STOCKTON, CA 95201 p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q (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. t CP Job Address _ /_�r) yo e47T/`1 XA City Lot Size/Acreage Owner's Name 1-f7lh 04 Address Phone Contractor 1�� S �ddressla Ll�f.�CLicense;rvo" Phone_de � TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ �DESTRU TION 0 Out of Service Well ❑ PUMP INSTALLATION,' F SYSTEM REPAIR" El �OATHER�0 -_ _14 6nitori4 Well C7 DISTANCE TO NEAREST: SEPTIC TANK 60 .4-'SEWER LINES" DISPOSAL FLD.K--�" PROP. LINE / FOUNDATION r AGRICULTURE WELL LINES- DISPOSAL WELL PITS/SUMPS Z1 INTENDED USE TYPE OF WELL PROBLEM AREA,._ ONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well•Excavafion — Dia. of-Well Casing Z r Domestic/Private Gravel Pack } ❑ Tracy Type of Casing- r Specifications I'1 Public 1-1 Other . , FT-Delta Seal .Type--of-Grout I I Irfioalion .02.-T0App(ox. Depth' I-).Eastern Surface.Seal Installed by _ !. Re air Work Done 0 T p`'F L k r? z p Type of Pum H.P. _�� f ^State Work Done _ Well Destruction ❑ Well Diameter Sealing Material &Depth 4A 'FillertMsterlal-6 'Depth p TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION t I DESTRU.CTION I I INo septic system permitted it public sewer is { / k, V i y1,'" i 4 1 ._r\- i available;wilhin 200 feet.] f Installation will serve: Residence Commercial-_ Other ^""� -- - ---- -- - Number of living units: I 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 f { Distance to nearest: Well Foundation Property Line LEACHING LINE D No. B-Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line t k� SEEPAGE PITS i-I Depth - Sire Number SUMPS CI Distance to nearest: Well Foundation Property Line 7 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 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 applican st r quirad ' ompleta drawing on rever ide. �^ I Signed ills: "` Date: FOR DEPARTMENT USE OldY Application Accepted by Date Q _ Area Pit or Grout Inspection by s Date k/32 AY Final Inspection by [Data Additional Comments: 112 _�✓/� C3/ �� r;f��r/> {� pfj P�//( � ;��9T JY✓1��1/d7%? Applicant -Return all copies to: San Joaquin County Public Health d z964-P 'U�f Services, Environmental Health Permit/Services n� :1661 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 I�l1Nv- INFO AMOUNT DUE AMOUNT REMITTED ASR ' RECEIVED BY DATE PERMIT NO. _EH A-26(REV.f K 51 t Oa $n a a i