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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL. HEALTH DIVISION O . 1601 E. HAZELTON AVE. , PHONE (2.09)468-3420 SAN JOAQUIN COUNTY•PUBLIC RERi.IN STOCKTON, CA 95201 ENVIRONMENTAL ES 1 YEAR FROM DATE ISSUED SPEC1ALJPr,XMJL1Fmp1ete 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 /P_ubliicl/Health Services. Job Address , d l i 1 o rVA+ZTj� /�(9« I /_ City ' �f7Vh_��rV1 Lot Size/Acreage Owner's Name b0✓I✓1 GC G�V(]1ne( Address f1LW V"r Jf `� 3q ? vin � � Phone � J(fT rr r9v� icl� AlS E SL k�e� s Contractor S C� ddress_ __ I— Q� (�S ( 7_S Il�� Phone IZ License No. TYPE OF WEL /PUMP: NEW WELL WELL RE? CEMENT Cl DEST, UCTION 11 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTE AIR ❑ _ ' 1 OTHER [I Mcinitorin Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ---- DISPOSAL FCD. _ PROP. LINEyi�A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial U Open Bottom If Manteca Dia. cif Well Excavation tVic 7 In �t 1,��— Dia, of Well Casing (I Domestic/Private �( Gravel Pack I-1 Tracy Type of Casing FU Specifications Il Public I l Qiher (1 Delta Depth of Grout Seal _ - I I hri ation Type of Grout cftV-Ewl p' zS Approx. Depth I I Eastern Surface Seal Installed by_C�}dZk k-- Repair Work Done U Type of Pump 14 p State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo Septic system permitted if public sewer is Installation will serve: Residence _ Commercial— Other available within 200 feet.)_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK - ---- — --Water table depth ❑ Type/Mfg _ PKG. TREATMENT PLT. ❑ Capacity___,_` No. Compartments Method of Disposal Distance to nearest: Well .. Foundation Property Line LEACHING LINE LI No. & Length of lines _ 1 — Total length/size____ FILTER BED 1-1 Distance to nearest: Well - _ Foundation Property Line _ SEEPAGE 'PITS I I Depth —. Size --- -------- - ---- --- SUMPS LI Di --- Number Distance to nearest: Well Foundati DISPOSAL PONDS EJ Foundation --- Property Line 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 compow-ation 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. W. Signed X dad- Title: L ��y_ 1 /I ��fZ.�-- Date: I U/10 /�O FOR D ME E ONLY Application Accepted by Q Z c V -- - Date � 7 Area Pit or Grout Inspection by n Date X n Final Inspection by /- Date Additional Comments: t` G ro a 15 (;p �� 11 oD/_ E'rf . Applicant - Return all copies to: San Joaquin County Public Health Services, Fnvironmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CK� RECEIVED BY �r _ CASH DATE PERMIT NO, EN 13N(REV.ria Sr �.■i— L/�/� a y EH -4 26 (JX/7 I/ -- �y 7v w/