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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 f!B MIT MIRES 1-,YEAR FROM DAIR ISSUED (Complete in Triplicate) Application is 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. 549 and 1862 and the Rules and Regulations of San # Joaquin County Public Health Services. y Job Address 7 S 1 E. (�� Stf-e-et - ---------- - City Lot Size/Acreage r _ Owner's Name 6f!ff f AJet�UY► Qn —.Address )DO, R 30010 s Phone - Contractor Address 26 Z8 egist MV ekLle.,S*A• S122V Phone ��S�g7I License Nv. �} TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM�REPAIR L7 OTHER 0 Monitoring Well.20C DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES �� DISPOSAL FLO.SIV PROP. LINE 75� FOUNDATION AGRICULTURE WELL —&ZA— OTHER WELL yo, PITS/SUMPS AdE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing 1.1 Domestic/Private )W Gravel Pack 1'Tracy Type of Casing RV Cs Specifications H Public I.1 Other F1 Delta Depth of Grout Seal _ j6 _ Type of Grout Nem C.0 O E. I I Irrigation 2-5-Approx. Depth I I Eastern Surface Seal Installed by mss'.tG�7rIAM _ __ Repair Work Done 0 Type of Pump H,P. State Work Don _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 Yf" SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number _ t n SUMPS Ll 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 for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all require inspections. Complete drawing on reverse side. 7 Signed X V�(lA- Title: CA R C E Nn. S'�2 2 ,� Data: vim..- (2, 7 9t7 FOR DEPARTMENT USE ONLY / 4 � Application Accepted by � `"r << r Date 1 - Area t 7!/ Pit or Grout inspection by Date Final Inspection by +- :, Date!/ - / ' Addal m itionents: Z ° 1-0• 1Z& Applicant - Return all copies to: San Joaquin County Public Health I Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �7 t7/' EH 13-24(REV.rias) X v /f 4 op ! - �a X33 -� EH 14-2e [) CCJI ! /