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APPLICATION FOR PERMIT SAN JOA OUNTY PUBLIC HEALTH SERVICES NMENTAL HEALTH DIVISION HAZELTON AVE. , PHONE (209)468--3420 goo 0O BOR 2009, STOCKTON, CA 95201 ;5�a EXPIRES 1 YEAR FROM DATE IUSUED (Complete in Triplicate) Applica ereby 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. �y� Job Address L"e- City L`-� i Lot Size/Acreage JC � PrW� '� S11 u Owner's Name '� ev o "" Address CA t �� Phone fb �3a -7Z1p gfta- Contractor t t Address L rn &4.9 5&44 License No. SgI603`I5 Phone 946-23. 5 TYPE Of WELL/PUMP: NEW WELD WELL REPLACEMENT 0 DESTRUCTION V Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER C] Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ lam_ SEWER LINES la' DISPOSAL FLD. PROP. LINE y FOUNDATION S� AGRICULTURE WELL �_ OTHER WELL__E� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation >r �� Dia. of Well Casing {-l°- S-Zrr ❑ Domestic/Private .9 Gravel Pack ❑ Tracy Type of Casing SM 40 PYC. .__-- Specifications 1 n FI Public 17 Other F1 Delta Depth of Grout Seal ^'tS Type of GroutRer r L 11 Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done 1 'y -(p«5-2-0 Sealing Material & Depth Well Destruction ❑ Well Diameter 1 � Depth Filler Material & Depth fP TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted it public sewer is available within 200 feet.) Installation wilt serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity - -_ No. Compartments l , PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line I 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 applicacRImust call for all required i spections. Complete drawing on reverse side. Signed Title: &2/wl_4 Date: Y w �cif t FOR DEPARTMENT USE ONLY 11 Application Accepted by Date a Area 3 J Pit o ra Inspection by Date olf-4 i1,., Final Inspection by Date ` Additional Comments: o f KO� Applicant - Return all copies o: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTEE) I C K I RECEIVED BY DATE PERMI-f 1 EH 13-24 MCV.t i n 5) 2� 1 Q T EH 24.26 ` —i