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�M 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 RZMIT EXPIRES_1 YEAR FROM DATE ISSUED �,/b,c�Om fete i ip bate) Cy aC�4 o Application f s here made to San J fV01 Z� 2b--7� !— 0 Pp by 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. �P/t.� 7--z- Z—QG O - 0 l 6 — Job Address _ �,'/�L� t -�a�;^� 1 �• MgJLJ - - City �1d/�r //J Lot Size/Acreage Owner's Name -,&)_4 7Z (M K P4910� Address © Ly /U4C ® a lOL e�' Phone z" 5 Con traciorw� Z-Actress �8�� L ei License No. z Phone 8� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M or 5-&, Test 8lu� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 10—L/V, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom ID Manteca Dia. of Well Excavation Bia-aHflfeN£�ing�r��U�� CI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing SpeeiiitMtvns f'1 Public Cl Other 1-1 Delta Depth of Grout Seal 'Type'8f'G?out I i Irritation .._.,,„ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I 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 Character of soil to a depth of 3 feet: Water table depth r ,� SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments V1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number LJ SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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; "1 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 m call for all re 'ad insAections. Complete drawing on reverse side. j Signed t Title: 6 ltd LSA` Date: FOR EPAATMENT USE ONLY 1 Application Accepted by Date Area Pit or Grout inspection by Date Final Inspection by Data Additional Comments: a Applicant - Return 911 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO A�M{O`1UNT DUE AMOUNT REMITTED 1' H RECEIVED BY D�A-T�E�j C�PERMI TNO, . ENt3.21IREV.+/xsl W EH 71.2E 1