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APPLICATION FOR PERMIT RECEN' �1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + ENVIRONMENTAL HEALTH DIVISION AUG 13 19,919 '191 1601 E. HAZELTON AVE. , PHONE (209)468--342SNVIRONMENTAL_ HEALTH P O BOX 2009, STOCKTON, CA 95201 ,.PER I /SERVICES RMWIT EXPIRES 1 YEAR FRPM DATE ISSUR (Complete in Triplicate) !I ' Application is hereby made,to San Joaquin County for a permit to construct and/or install theSU 11.5i4WbIribed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 aF{d t}g Vl +�d�Rhegul�holnsof San Joaquin County Public Health Services. SIV i[ J '1 AI H 1�.r,t-al P�R�I�lia��> �VIt.;ES i Job Address ity Z �S�Lt "h�r Lot z e Owner's Name Russel K a g e h i r o Address 7200 W. 11th St. T—rac_y, CA 95M Phone 835-, 094 Contractor_Howk Systems Address 1825 Yo-mite Blvd. MDdesto License No. Phone 529--4110 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION_ ----_AGRICULTURE.WELtr OTHER-WELL — "'�' - - PITSYSi1MPS INTENDED USE TYPE OF WELL YJPROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public Cl Other n Delta Depth of Grout Seal Type of Grout IUlflrr;Ration Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump Dom' H.P. 200 " State Work Done New.installation. 11 r Well Destruction O Well Diameter Sealing Material & Depth '�C} Depth Filler Material & Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1 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 i PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line ' b LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 such manner as to bec a subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the fotlo ing: "I certify that i h ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C nia." The applican t call for all,Ann ctions-Complete drawing on r & e ide Title: Date: -FQR DEPARTMENT USE ONLY Application Accepted by Date A Area Pit or Grout Inspection by Date Final Inspection by Date Z� 14 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 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. E INFO . EH 1324 tREV,tinsj_0_0J-CJU EH r33�v 9 yrs �o —2363 1 34M i -