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- "Ar APPLICATION FOR PERMIT <.., SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE'.'',-PHONE-(209)468-3420 P 0 BOX 2009, --STOCKTON, CA 95201 PE MIT 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 describik. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of S8a Joaquin County Public Health Services. Job Address _32017 eks_r �26H_ M 1 LE,-R-p City'sTDCKTDIj Lot Size/Acreage 4 D lift V Y G�rn/�2S R Q-_96 t 1�I:�Mod 'b- S3S Owner's Name Address hone ContractorKCELTC.�-I Address-" rb7`t ClheiCS' /s'T, L��se No S-�Phone- 5 o TYPE OF WELL/PUMP: NEW WELL. .•g _„.._� WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ;,❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR a OTHER ❑ ring DISTANCE DISTANCE TO NEAREST: SEPTIC TANK•"''SEWER LINESDISPOSAL-FLD. - - - PROP, LINE �Qf - FOUNDATION O AGRICULTURE.WELL OTHER WELL I= PITS/SUMPS INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + � D Industrial O Open Bottom ❑ Manteca _ Dia. of Well Excavation Dia. of Well Casing” _ Cl Domestic/Private EL Gravel Pack - ❑ Tracy - --. Type of Casing C, F480 Specifications /� ' ,r Public n Other XDeita Depth of Grout Seal 65J Type of Groutg 611 aT I Irrigation ��Approx.Depth 1 I Eastern Surface Seal Installed by e aipWdrk Da°�ewtp T — p Type of Pump +� 1 H.P. tate Work Done_ Well Destruction Well Diameter 11 Sealing Material i Depth ��-! Cr✓NI!NT � 0"-,S 7 �, Depth I& 7 9 _ Filler Material i Depth cSA'1J b-57 9 GT.. _ .. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other - w---- - Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments -- PKG. TREATMENT PLT.❑ - _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of limes Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line � ' q i; SEEPAGE PITS I I Depth Sire Number SUMPS L] 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 i 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." Contractoes 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 nAlecall for all r ad i spectkm. Complete drawing on reverse side. SignedK Title• H(ek0.8_ I0LQ& s'TDate: 01i ,�-Z FOR, EPA ENT USE ONLY Application Accepted by Date z Area - Pit or Grout Inspection by Date Fina! Inspection by Date 7- 1T? q 2 I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Snironmental Health Permit/Services 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201FEE i Jjr fO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE 1MZl1tyPERMIT" Efi NQ. � • Ell(REV.ti� La SY j.+ Ag N - �.aQ�LJ.