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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)465-3420 P O BOR 2009, STOCKTON, CA 95201 RES 1 YEAR FROM DATE ISSUED � f ryJ � � (Complete in Triplicate) Ds, icgion isw ereby m�Se to Joaquin County for a permit to construct and/or install the work herein described. This application�ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County_Public Health Services. Job Address S t7G�C " City L�'k7 Lot Size/Acreage t' Owner's Name M1142F W?0"JLiA306 ECL`A-14ild YZI? C t"ff D STS GG- (fz ddress �'�-� Phone ContractorA/g)AJ-e4t-;-&1-'L%ddress 3 z I s ��h/�"l�� License No, 07Q:7 Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION,❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR G7 OTHER 1 Monitoring Well D DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF_I_CATION * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2 pia. of Well Casing Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications �l! I') Public Ci Other fl Delta Depth of Grout Seal Type of Grout-SorL K&27 ;S I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done -7,6 7C,%7-4-%-r4,5 ��" 7,6 ^. Well Destruction ❑ Welt Diameter Sealing Material & Depth Soot- S Depth Filler Material 5 Depth SOrL [NtTr-+G S _ C� crCr/YJ�i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I l INo septic system permitted if public sewer is available within 200 feet.) Y 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 } PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I Depth Size Number SUMPS\1 UI Distance to nearest: Well Foundation _- - Property Line DISPOSAL PONDS D 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 6r 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 applicant must call for all require inspections. Complete drawing on reverse side. Signed }(— QGJO ` Title: QLott -7 Date: FOR EPARTMENT USE ONLY Application Accepted by Date---b--= �/71"LArea Pit or Grout Inspection by /f DateFinal Insppeccttion by - Date 2 Additional Comments: `� +� ` f-& + Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 EFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. er,14tf�3-25