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� k , - APPL I CATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC BMALTH SERVICES :. ` 11 - - ENVIRONMENTAL HEALTH DIVISION ° " 1601 t. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 :DRRYTT EXPIRES 1 YEAR FROM DAM—MO—ED ' (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This M application is made in compliance yitsh San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin Count ablic Health Services. • City_T� Lot Site/Acreage Job Address .4 2` 1Cr�d Address Witt . CTFr -!nphY Owner's Name ^)' aj; rS � r Gob- 003 Contractor '-0"` ou"L" N `'r Address License No. Phone `f __ TYPE OF WELL/PUMP: --. NEVJ WELL.,.❑.„___. WELL REPLACEMENT ❑ DESTRUCTION o Out of Service Well Ll OTHER ❑ Monitoring Well L7 _. E PUMP INSTALLATION ❑ y� SYSTEM REPA1Fi`C7° '�= =� — DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 's -41 °. FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED' INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A Industrial ; ❑ Open Bottom -,f❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 11 Gravel Pack{ 0 Tracy Type of Casing Specifications I'I Public l C) Other n Delta Depth of Grout Seal Type of Grout I I Irrigation A —.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t H.P. State Work Done— Well Destruction ❑ Well Diameter: Sealing Material & Depth Depth.. ` '- ='� " ' Ff11er Material S Depth TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION I I DESTRUCTION-?l (No septic system permitted iip9blewer is i available within 200 feet. i $�'f- t w Installation will serve: Residence S_] F Commercial Other c�rn� t, Number of Living,units: --/— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK V Type/Mfg Capacity C! . • No. Compartments PKG. TREATMENT PLT. ❑ d2G2�d ^� et `Mhod of DiffSal / hr�� I Distance to nearest: Well-16 ob - Foundation_ AIA - Property Line r LEACHING,LINE No. & Length of lines 5 Total length/size S FILTER BED £ 1:1 Distance to nearest: Well Foundation Property Line t s , SEEPAGE PITS! € Depth -Size y Number SUMPS CI Distance to nearest: Well Foundation Property Line 1 DISPOSAL PONDS ❑ F I hereby call 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 agairl 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 ome ubject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature j certifies the following: "I certify rn the_perfor encs of the work for which this permit is issued, I_shp,11_employ!persons.subject to workman's compensa- ti nliva of California.''=60e I The appfic mus ions. Complete drawing on reverse side. J SignedTitle: n � — Date: - _ or Application Accepted by Date A ea o awvr,.C.v6u A-670 i"_79".471 e Pit or Grout Inspection by r Date Final Inspection by 'ur Date / l( !may Y ✓ 4 J•e2. ------ Additional Comments: :,. .. Applicant - Return all copies to: San Joaquin County Public Health iServices, Itavirontsental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO r a EH 13-24 ill I/It.51 Q K, n k £H 14-26