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APPLICAT10N FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION -3420 <br />1601 E. HAZELTON AVE., PHONE (209)468 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES I Y R DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made , to San Joaquin County ror a permit to construct and/or install the work herein described. This <br />application is made in cciii;iliance with San Joaquin County Ordinance No. 549 iknd,�.662 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />E 2- <br />Joo Address City ia&�t Size/Acreage 2` <br />Owner's Name Addfess /Z 6 31 4E - "--- - - .....-Phone <br />11 1 ) _" 11, A :— <br />Contractor J9&A!t4 dAJ=J40 Pfk"A"4ss I 1--i _An�r_� <br />TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEME <br />PUMP INSTALLATION C YSTEM Ry, <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE , <br />FOUNDATION AGRICULTUR W"/L--- <br />INTENDED USE <br />C-1 industrial <br />' 1 Dorr*stici Private <br />"I Public <br />i I littuaoon <br />Repair Work Do" 0 <br />Well Destruction 0 <br />TYPE OF WELL <br />L! Open Bottom <br />0, G(avei Pacx <br />olhor <br />— Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA <br />,,71 Manteca <br />0 Tracy <br />I'l Delta <br />I) Eastern <br />iv —1 <br />�'L,icense No- Phone �!VH2_2 <br />D DESTRUCTION C_) out of Service Well 0 <br />- Monitoring Well <br />A LID, OTHER D <br />DISPOSAL FLO,— PROP, LINE <br />OTHEAWELL_ PITSISUMPS <br />XTRUCTION SPECIFICATIONS <br />of Well Excavation — <br />of Casing -- <br />h of Grout Seal <br />�* Seal Installed by <br />(P. — State ork Done <br />Sealing Material & Depth <br />Filler Material & Depth <br />". of Well Casing <br />Specifications <br />Type of Gro <br />"rYPE OF SEPTIC WOAK� NEW INSTALLATION V� REPAIRIADDiTION 1 1 DEWTRU 710111 1 (No.lsaplic system permitted it public sewer is <br />ava� able within 2W toot.) <br />installation will serve: Residence -Z Ccimrnetcial JV <br />'her <br />Number of living units; — Number of bedrooms t_A�_ _ <br />Character of soll to a depth of 3 feet: Of Water tab4s depth <br />SEPTIC TANK 0 Typ*i Mfg L C At2.w�-A&Ao — Capacity No, Compartments <br />PKG. TREATMENT PLT. 0 - I Method of Dispcis4 <br />01"ance to nearest: WeR Foundation Property Line <br />LEACHING LINE 0 No. & Length of lines 112,J y 0 Total length/34e_ <br />FILTER BED Cl Distance to nearest. Well _r0_Z1*undsvon -Zili&4L Property Line <br />SEEPAGE PITS I I Depth _-.2--i- o0 si. <br />IV <br />SUMPS L I Distance to nearest Well Foundation Property Line <br />nISPOSAL PONDS 171 1 �1 <br />I hereby certify thSt I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an, <br />rules and regulations of the San Joaquin County <br />Home owner or licensed agent's signature certifies the following: -I certify that it) the perlorniancs of the work for which this permit is issued, I shall rvot <br />employ any person in such manner as to become subtect to workman's compensation laws of California." Contractor's hiring or sub-contfacting $ignstura <br />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- <br />tion laws of California." <br />The appficanirst call or squired <br />'inspections. Complete draw4ng on reverse ii�de. <br />Signed X '44_ Title: Dew <br />IF DEPARTMENT USE ONLY <br />A i Area <br />Application Accepted by C mczl�-Ir- — Data <br />" 60.4. A I,- - '_ , , <br />Pit or Grout Inspection <br />AddiWnlil COMMOMC <br />)plicant - Return &.11 copies to: San Joaquin Coarity Public Health <br />Services, Environmental Heall.h Permit/Services <br />1601 9. Razelton Ave.. P 0 Box 2009. Stockton, CA 95201 <br />im 13,24 lAry S <br />EH '4,M <br />*1) � A, <br />Data I V <br />77klve.�,__ <br />i I <br />FEE <br />INf`O <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK 31 <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT NO. <br />I tE <br />9 <br />9C) -/a�9 <br />