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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �j ENVIRONMENTAL HEALTH DIVISION A Y4fEJV� 1601 E. HAZELTON AVE. , PHONE (209)468-3420 R'eccllr - P O BOX 2009, STOCKTON, CA 95201 OCT " SAN JO � 1 1nn1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,��L'BI j�,F Ap(IIN(,PI.. (Complete in Triplicate) Lr'OTq L/:�{ .. ; Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein r�tetrib�d.; is application is made in compliance with San Joaquin County Ordinance No. 49 and 1862 and the Rules and Regulations r5f &W Joaquin County Public Health Services. ,,-/ Co PF-S;rL V b ao w, r7 v kel vA le- T Job Address U 08o "w�'1 -ron 44 1 City Lot Size/Acreage Owner's Name , 04#1I%— G AfM Address 1206 w. S7XWC& 04076,5 C•9 Phone V If - 30 S ro rx'r+n, cots-1-0r Contractor Se&'6'kwt &A40W7fV-#y Address 2J'2r F. �Y�[T�E S 7.- License No.e4s-?"J,921JI Phone TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE M U L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .0 in• Dia. of Well Casing Z 1-1 Domestic/Private gGraval Pack Cl Tracy Type of Casing FYro Alf- Specifications 11 Plrblic 1:1 Other n Delta Depth of Grout Seal y Y, Type of Grout_ .I I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by GM-&. c-6, t Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Materiel i Depth 4ewr e✓wr 6e,4a.,:-O.e (` Depth ►Piller Material ♦ Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 1 LEACHING LINE C1 No. ♦ 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." Contractors 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 'nspgctions. Complete drawing on reverse side. Signed X_-AA-,k- H• ��- Title: Witgn2}IN CA V1 r E"(Z _ Date: 10/T 191 R DEP T USE ONLY y l/ Application Accepted by _ Oate (_ 94 AMIS Pit or Grout Inspection o2 pection by— ! Date Final Inspection b Datt►// yi Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health � Services, f33viroamental Health Permit/Services n�r 1601 t. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201FEE y INFO AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 113 13.241"Ey.,,"sr \(\� 2c1 oma EN 7b t