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APPLICATION FOR PERMIT �.. �. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION t 1601 E. HAZELTON AVE. , PHONE (209)468-3420 f P 0 BOX 2009, STOCKTON, CA 95201 I EXP RLS 1 YEAR FRCIU DA ED ffFP_,E,s.JO 4-vC .' (Complete in Triplicate) Application is hereby made to San Joaquin County fora l b 3— b&0-1-7 application Is made in campllance with San Joaquin County Ordinance No. 549 andruct o1862eand thetall Rulesandwork eRe described. This Joaquin County Public Health 8e�rriXes. Solations of San Job Address 2C Y� �H T�s2 ia/AY ffn/0 O 72- 1&3-A60--U� �� „ C�tY .S/� Lot Size/Acreage ,Z Dwn'r's Name SAN 7bgQv,,,r ddress Z333 Si^I A4,-P-1 mo"q-r ga�4 C� (��T�P4�. IS N /moi°1 TrEs '�.It a,y f .�QPhone r Contract N o E f^, r^�� _Address fi'r7 License No. P�tl7L�0 Phone TYPE OF WELLIPUMP: NEW WELL p �b_ Z WELL REPLACEMENT DESTR CTIOp��7 Out of Service Well ❑ PUMP INSTALLATION ❑ i>J� SYSTEM REPAIR ❑ �ER� Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK gEyyEp LINES `—��EST�.iy � /�!.-� ---�� DISPOSAL FL l�dP.FINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N E7 Industrial ❑ Open Bottom ❑ Manteca t7 Domestic/Private ❑ Gravel PackD1s. of Welt Excavation Dia. of Well Casing ❑ Tracy Type of Casing 1 I'1 Public C] Other II Specifications "' oe Delta Depth of Grout Seal / � Cv79'rrG, I 1 Irrigation �.. Approx, Depth I I Eastern Type of Grout4 Repair Work Done. U Type of Pump H P Surface Seal Installed by — Well Destruction O Well Diameter Sealing Material 6 Depth —y state Work Done � Depth Filler Material E Depth _Vpf4- Gr/—i T`r,.rG r `fir TYPE.OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence` Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK. 0 Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No, Compartments Distance to nearest: Well Method of Disposal ' Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: WaitFoundation +. Property Line SEEPAGE PITS 11 Depth Size SUMPS Number LI Distance to nearest: WeII Foundation DISPOSAL PONDS ❑ ' — Property Line 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 m t call for all r quired inspections. Complete drawing on reverse side. Signed (�, �� Title: I �&_S�.�/7 44ate: 7 f ' F R DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by V Date Area Additions! Comments: Date � Final Inspection by to 7 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 AMOUNT DUE AMOUNT REMITTED��RECE�IVED INFO DATE PERMIT'N0. . EH 13.24(REV,i/H51 EH 14.26 1.Jv'.�Z� //'t i N L/V rrWZ � y I~