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2V-2.2o/S2-000 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - 1601 E. HAZELTON AVE. , PHONE (209)468-3#2U , P 0 BOX 2009, STOCKTON, CA 95201 PERMITRES 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. Sao N p,Tt �I �/ r/ Job Address _• c'S �� _ -__-_ City !'A ff Vlw0 Lot Size/Acreage Owner's Name Address �u»�''✓l +tlsr!�/[oe+.G78_- Phone 41' Y68 2180 . STac it T�+I! Contractor u Address.2s-ZS' E. &_V& 4F _It-_License No. S�.Z.ZC�S_ _f hone *JO 1'Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FJ DESTRUCTION )6 Out of Service Well 19 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 * Industrial ""Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public I-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Sate Work Done_ g Well Destruction 4{l Well Diameter � _ Wit. Sealing Material A Depth (fGGh sin Depth L9G Fir_ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 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 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. 8 Length of lines Total length/size FILTER BED ❑ 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 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 appli ant m t call for all required ins , tions. Complete drawing on reverse side. Signed �� Title: ��0 tCr C.&r o Gies'T Date: �� FOR DEPARTMENT USE ONLY Application Accepted by _�I�VYIf�C i!t fe- Date 2 Area 29 Pit or Grout Inspection by Date D Final Inspection by 4 Date 10 7 Ft al] Sarir� C�-,na-,c� Additional Comments: Irtall " 14 1 l0 s 5b `F8 D Tre4%ALA-L —ibor 1 l59v 10qu-0 �a Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ll 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA95201FEE \ INFO A�M/OTU�NTTCK L DUE AMOUNT REMITfv� JTTED CASH !RECEIVED BY DATE EH 13-24(REV.1/n 5) Y_ J.W / / _n I ! 1 Q Y7- 19PERM17'NO. Zy � EH-2e L�� i./ L�