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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '04 )" ENVIRONMENTAL HEALTH DIVISION &,t-.0 kr VF 1601 E. HAZELTON AVE. , PHONE (209)468-3420 S 86,p2e/ P O BOR 2009, STOCSTON, CA 95201 p "1N� 0 ^, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fti��0NMfN qp 0NSU//N� (Complete in Triplicate) lNfq�j�*L, fs llU/j/ Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. TiVI�' application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. n �n� ,� —j(� Job Address 2.(y 1�0 �0 r(N 1 ' o o'd City 'V`(}�Y� n Lot Size/Acreage t y � Z C) rt Owner's Name � )IOVIn . C 6kAddress W, r"1<�, M� Phone-7, 3 Contractor 4dressEVI V, � SOQe No.ro"5-1Z28one�9 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATIO O SYSTEM REPAIR O OTHER ❑ Monitoring Wevii DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w�' 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial Cl Open Bottom O Manteca Die. of Well Excavation i - Dia. of Well Casing !✓l. [I Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications ['I Public Ia Oth,�� n Delta Depth of Grout Seal Type of Grout�y`y ^ 1 1 Irrigation �SRpprox. Depth I I Eastern Surface Seal Installed by tti r Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is O 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, Cl Method of Disposal C7 Distance to nearest: Well Foundation Property Line "% S LEACHING LINE L-I No. & Length of lines Total length/size FILTER BED 1=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size __ Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 applicant must call for all required Inspections. Complete drawing on reverse side. g Signed X e -4Z( � Title: -S_0"/Cf 6-,-p�V4y S x- Date: -//1,71,91 FORC�o USE ONLY y 23 Application Accepted by71Z Date �j r J a Pit or Grout Inspection by Date �'` s"f�Final Inspection by Data/ : q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health A Services, Environmental Health Permit/Services Od 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY ^ CASH DATE PERMIT'NO. . EH 1324 IRFV. iin FH A 26