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APPLICATION FOR PERMIT I 11i. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 iIMMIX RS 1 YEA R FROM DATE ED (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4 Wa+ City L-bk Lot Size/Acreage ` Owner's Name 1! fOLMa,r �v�L. .� Address 5 �•�fn�fOE S r~I��r� CA32-3Q Phone as82 -oZ4I �1 �_ � 3133 F.+ crald kdF Contractor W S'l k.,,(Address �c�° �atoJG CA `54.70 License Na CGS4[t-l75J Phone&14 138'7276 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well Q DISTANCE TO NEAREST: SEPTIC TANk SEWER LINES DISPOSAL FLD. PROP. LINE p� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS '4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ra Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1-1 Other 1 171 Delta Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump'1 Hip. State Work Done Well Destruction `j Well Diameter i LG- Sealing Material & Depth ft 1,.o e:. t'At 1, 144 r Depth t Filler Material & Depth 6LS 4LOyc i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.j Installation will serve: Residence_.._ Commercial_ Other �� Number of living units: p Number+of bedrooms Character of soil to s depth of 3 feet: Water table dept o SEPTIC TANK. O Type/Mfg Capacity No. Compartments # 92 PKG, TREATMENT PLT. ❑ Method of,,pIOAQU` Distance to nearest: Well Foundation rur'LI HEA°t_Tt Property Linet I;+ >E >r{[; !1 cI 7&H LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth I Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I A� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la rules and regulations of the San Joaquin County ws, an 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature fi,l 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 compens V tion laws of California." The applicant must call for allrequired inspections. Complete drawing on reverse side. � D I ,j.I Signed X t� vt t Title: GOO of �� V. {/f,D"t (f"+S- Date: O �Z FOR DEPARTMENT USE ONLY Application Accepted by Date /0 Z Area 0-PI Pit or Grout Inspection by Date FU q Z Final Inspection by Date 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 FEE AMOUNT DUE / REMITTED I_ INFO /y CASHRECEIVED BY /D/gTE PERMI7'N0. • EH 1 .25 IREV.l i n sl b G V 0� ,t l,b /J/ — d f d 3�y7