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f APPLICATION FOR PERMIT j1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PF,HMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s 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 San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /� Job Address ;2_15'-3o _ dJ i�(.c I�C/ _ City C, Lot Size/Acreage i p , Owner's Name Address 13 2-3 .t,CVA-A_)S •5'7r 7,4-74G� Phone 8'36 -- 1-57 w�. Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 9 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL- � OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " 177 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private _❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public {.1 Other f1 Delta Depth of Grout-Seal-- - - -- Type of Grout I I Irrigation —,-,Approx. Depth I il Eastern Surface Seal Installed by Repair Work Done Lli'Type of Pump H.P. State Work Done_ Weil Destruction 'Well Diameter to Sealing Material & Depth ,�oG �fJJT2n]� + di!�K 7n Depth Filler Material & Depth 7ZI P. TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 6 available within 200 feet.) ! Installation will serve: Residence_ Commercial Other I 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. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines, Total length/size + j FILTER BED ❑ Distance to nearest. Weli� . Foundation Property Line h j 1 SEEPAGE PITS 11 Depth Size Number SUMPS Ci Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 fol which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica st call f all red inspections. Complete drawing on reverse side. Signed X Title: _ _ Date: FOR DEPARTMENT USE ONLY 9 Application Accepted byVDateIfthff 4 i Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i.- L.),4 •- 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 INFO AMOUNT DUE AMOUNT REMITTED CK 4- RECEIVED BY �y DATE PERMIT'NNO.. + EH 13-21 IREV.r/14 5) Q_ 6 _ t �ef Z((' _ t �t� SIO Y/�✓1Q EH 14.26 L