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' 4 # APPLICATION FOR PERMIT `r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Z' �. ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRES- 1-YEAR FROM DATE ISSUED N l 7? //7 omplete in Triplicate) 16 Application is hereby made.toSan lL uin 1ou y'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. Jab Address' s C '/ 4!Oi M!c kF Gj"dv_.5 R`�7 b. __ City LD h f - Lot Size/Acreage Owner's Name CVl_ V� �ddress q•5as we �1q� L&I It:;;L— Phone 5 Contractor Address L4J C License No. ftlone -5 -% TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT h DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR © OTHER ❑ Monitoring Well 0 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 SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C-.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern T Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction 0 Well Diameter Sealing Material & Depth �} Depth Filler )Material & Depth v - TYPE OF SEPTIC WORK: NEW INSTALLATION L._-IMPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence_ Commercial—L—tither - Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: C�- Water table depth SEPTIC TANK 9--Type/Mfg _ C C-F^ f Capacity- No. Compartments �f- PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well ,Tdty+ Foundation .- 4210_ _ Property Line 5 �0 LEACHING LINE L4- b. & Length of lines _ l 0-0 Total length/size 01 1 , FILTER BED ® Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ff SUMPS &—t5istance to nearest: Well Foundation �U f Property Line DISPOSAL PONDS ❑ f ��-- 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." Contractors 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-t taws of California. ' The ap an mus ca for req it d��nsi�oplate drawing on averse sid . i Title: — Da le: FOR DEPARTMENT USE ONLY Application Accepted by i .J.}■ ��--1_, Date Area Q) Pit or Grout Inspection by Date Final Inspection b �k Additional Comments: S 0 1, 1!t c w 0 r r` r 2-S -e P 01G +o tw4er Lpac.LN 1 ��-"et 8 t'] Ya _ Applicant - Return all copies to: San Joaquin County Public Health tr Services, Environmental'Health,Permit/Services - 1601 E. Hazelton Ave., F x 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. + EH 13.24 tREV.I H 51 �� ` r� �.0 �" 1 0 (/%w v EH 14-2e I �C 5 331L