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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 0 BOX 2009, STOCKTON, CA 95201 PE 11 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 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. _f Job Address �_7� 19.19A r^-� t I A Cil P City 4!!:4 ya Q Lot Si ze/Acreage _2 Owner's Name KV R=Cal 0Address ZZd 70 e- IA-2n 1[f & IId ne - Contractor. ( lJ K� Address T ��ILlr3 9Q 6Aa License NoZ f I383 Phone 'off TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT)ig ESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION SYSTEM REPAIR 11OTHER"i Monitoring1 Well DISTANCE TO.NEAREST: SEPTIC TANK J SEWER LINES • DISPOSAL FLD. � PROP. ,LINE FOUNDATION AGRICULTURE WELL �OTHEFi WELL PITS/SOMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r r fl industrial Open Bottom p Manteca Dia. of Well Excavation Dia. of Wefl,Casing Domestic/Private D Gravel Pack ❑ Tracy Type of Casing fn-Fe Specifications r' I') Public El��O7�thpr Cl Delta Depth of Grout Seal '� f -Typs ro4 k t7 YD I I Irrigation Approx. Depth 1 I I Easternurface Seal Installed by Repair Work Done ❑ Type of PumH . State-Work.Done_-'=`- Well Destruction ❑ Well Diameter Sealing feria] & Depth r Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONA-1-•DESTRUCTION I•I (No septic system permitted if public sewer is u -,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 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` r Distance to nearest: Well Foundation Property Line - J LEACHING LINE LI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest; Well Foundation Property Line iV Sl � SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I h J} I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and $� rules and regulations of the San Joaquin County w -' 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 m st tail for all required i spections. Complete drawing on reverse side. Signed f Title: Date: ,f FPR D ARTMENT USE ONLY Application Accepted by f Date y L p Area [ �� Pit or Gol ut Inspection by ata d Final Inspection by Additional Comments: Applicant - Return all copies-.to:—San Joaquin County Public Health 1 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IAF 0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH 13-241AEV.i/hsl '� �S(Z �'} �M-)73k