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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 I R.ESMIT EXPIRES 1 YEAR FRQM 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. 549and1862 and the Rules and Regulations of San i Joaquin County Public Health Services. kJfo��,:1 aa>a r w. Job Address f?'09,1 0E aro CKrf4 City 57'OM-i194) Lot Size/Acreage Owner's Name ©12rT O StOC TDN Address �- �t �1� 'T ► Phone ~ba ' �n,,nn f f e_ Contractor [�1�ihC_1t t.. i Address t'E�(.`� 16, IFf2CAh(WT License No.,TQ46 - 0a3 Phone -0/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTICTANK SEWER LIN ESi DISPOSAL_ FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ti Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ; CJ Tracy Type of Casing Specifications CI Public 1.1 Other ❑ Delta Depth of,Grout Seal Type of Grout i irrigation —_Approx. Depth f I Eastern Surface Seal Installed by _ Repair Work Done L] Type of Pump s Ct a H.P. _1�� 1 State Work Done_, �5',/�4�� Ll e Eaton Well Destruction ❑ Well Diameter,' Sealing Material & Depth _ _ _L Ajou,r} 4.ts'L.-L-. Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITION 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: t 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 I LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L3 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 ir 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 I 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 raversesidee.. / Q/ Signed Title: ._ 5��.1_s Date: FOR DEPARTMENT USE ONLY Application Accepted by DateA �-- Area Pit or Grout Inspection by Date Final Inspection by�—r v Date f 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 # INFo AMOUNT DUE AMpVNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 'r3-24 IREV.I/K 51 s ,n�i. ESN,,-,t�49.. f l ,