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_ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIX EXPIRES 1 YEAR FROM DATE ISSUED (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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .lob Address T� W, bot. lk [n is-r �T _ City Lot Size/Acreage �Q,Ccam° Owne('s Name )lata { Ili M I141-11- Address �v ; r+r� p6 Phone 20 �I —3tZ3 rr 36&3 0 e _ +',SL/fG 8 Contractor I d,�C•AddresslX?i(,Cto r� `�S7yLicense No,J5�y Phon&6)� ��y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Mo taring well C rft�S(�3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LEVE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 01t° ^, n Industrial ❑ Open Bottom ❑ Manteca Dia. of % Excavation /� Dia. of Well was g CI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ At Specifications I'I Public I:1 Other 11 Delta Depth of Grout Seal Type of Grout.�� 11 litigation __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump AI A H.P. State Work Done _ Well Destruction ❑ Well Diameter _I U Sealing Material Depth Depth":30 4r-, Filler Material b Depth r (Sr f- Ja�LLj TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial — Other Number of living units: Number of bedrooms /,(� G Character of soil to a depth of 3 feet: r`5 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line"^ a t' - I 'AU" LEACHING LINE 0 No. & Length of lines Total length/size— FILTER ength/size FILTER BED { I Distance to nearest: Well F A Mnation Property Line A2RS t^� C -r - TSEEPAGE PITS ll Depth Size —Number SUMPS LI Distance to nearest: Well F u at ion Property Linet-rIvy qv;' F S DISPOSAL PONDS 0 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 applicant must call for ail uired inspections. Complete drawing on reverse side. Signed X Title: Date: T FOR DEPARTMENT USE ONLY 9 / Application Accepted by Date Area " r Pit or Grout Inspection by Date Final Inspection by Date-5 / L 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 AMOUNTTr1EMITTED C / RECEIVE3D BBYYy� DrATE t/�Jj1PER/MIT''JN/On. EH 14-2I tF1tiV,Il n 51[INFO W� 7�� "`� X � '�_ :666 -5 " `j/v/� � /,,3 ) /1- //P EH i�de C� CJ