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u E .2 APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 SIT EXPIRES 1 YEAR FROM DATE ISSUED J (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., ` Job Address 2a 0 1,K) PA--\ City Lot Size/Acreage Owner's Name j?QV� T Q C aCV�Q1\�,! .. Address Phone j j q moo Com. `'15352 �. Contractor !'fe,17Y!tY__ Address `-O�� Qe�CAytr�1G�\P_ (1V4-' License No. CSS-2 513 Phone S -1 TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ _ _ DESTRUCTION 0 Out of Service Well 0 ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well ❑ 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 171 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation 10 Dia, of Well Casing ki7fI C1 Domestic/Private 19 Gravel Pack ❑ Tracy Type of Casing PNIC. Specifications 1 I'1 Public FI Other n Delta Depth of Grout Seal Type of Grout X Irrigation —.Approx. Depth I I Eastern _Surface Seal Installed b Repair Work Done ❑ Type of Pump _Sr2 __ H.P. I� State Work Done _ Well Destruction O Well Diameter, I Sealing Material & Depth Depth L.P M!b( Piller Material & Depth + TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I # INo 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 Capacity No:Compartments ' PKG. TREATMENT PLT. ❑ , Method of Disposal ' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i i FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ y 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 r 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 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 c��allrrff�or all required inspections. Complete drawing on reverse side: - - -�--� Signed Xs� 11as .» _ _._____ Title: �1 Otai tea. JS„ .._._.. Date: -7 `tel �1 l7 FOR DEPARTMENT USE ONLY ` Application Accepted by Date �� +y A ea Pito Grout I sWpeeiio^by f Date_�2_- `�(� nal nsp ction b Date (} Additional Comments: ` Applicant - Return all to: San Joaquin County Public Health ��>•KK i u S r aw{-e aw afrrdn Services, Environmental Health Permit/Services ,c� �;r C 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 952010 s � ( l IFEE AM TED T DUE AMOUNT REMITCASH RECEIVED BY DATA: PERMIT'NO. + NFO EH 13-24(REV.t/851 EH—2a u� o0 1 j a�-qfl 90—�lc