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. f APPLICATION. FOR PERMIT A� SAN JOAQUIN COUNTYIPUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTHDIVISION #J 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR- 2009,',STOCKTON0 CA' 95201 %P RES .1' YEAR FROG[ DATE (Complete in Triplicate) Application is hereby made to San Joaquin County for'`a permit to construct and/or `inetall the work herein described. This application is made in compliance with San Joaqui"n:County'Ordinance No:,549'•and•l662 and the' 'Rules and Regulations of San Joaquin County Public Health Services.. Job Address S ? �Y Q✓1 r ; Cit5��t/0 x"Lot Size/Acreage L{Q L/C F O Address. _ g$ �O f -�'o Phone ar�9�/7-Z Z Owner's Name /! r 7-f n Contractor 4 � P _1L�Iddress `� License N6- I Phone 57 3 g TYPE Of WELL/PUMP: NEW WELL _. __.,:,,-WELL REPLACEMENT,❑_ � _DESTRUCTION ❑ Out of Service We11 L"1 PUMP INSTALLATION lj�- SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES "DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ _ Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavatiom i Dia. of Well Casing S/ ( .OomesticlPrivate tGravel Pack- - C)-Tracy-•-•-•! Type-of-Cas -Specifications I'1 Public {1 Other' I1 Delta' Depth of Grout Seal Type of Grout Repair Work Done ❑ Type of urn Depth I I Eastern_H P. �Ijjace Seal Installed State U _ y _ p - � €Work Done- Well Destruction ❑ Well Diameter Sealing Material .Depth, Piller Material Ydr Depth TYPE OF SEPTIC WORK: NEW INST,ALL:ATION [.f- -REPAIR/ADDITION I I DESTRl1CTION-i-l'rINo septic system-permitted if pubfic•sewer is- i available within 200 feet:) Installation will serve: Residence Commercial 0"ther 1- Number of living units: Number of bedrooms 7""' _ Character of soil toad© Type/ depth e/Mf• �Gapecit SEPTIC TANK �ater_table depth: - 1 yp 9„w j. _.__ Compaitirierits ___ _ PKG, TREATMENT PLT. ❑ _ _„ _,. .- _t Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE Cl Y No. & Length of lines To length/size ' ry FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line 1 _. Q _ .. .. . -_. -. Number SEEPAGE PITS 11 � Depth Size .-_.,. SUMPS LI Distance to nearest: Well foundation ;Property Line ' DISPOSAL PONDS D 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 fo)lowing: 111.certify that in the pert.arrnance of the,work for which,this-permit is issued, I shall.no employ any person in such manner as to become subject to workman's compensation laws'ot 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 Calif - - I The applican ust callforall required-insW;pnns,Complete-drawing on verse side.-- Signed x /P�'f.lr� .-'' �✓� '+r k ide: � � _.„,/•i l ( ,/C Oats: i F;0 DEP_ARTMENT USE ONLY- 17 Application Accepted by f -Date Area - Pik-Cr Grout jxIspection by ate. 7 ?6 .Final.Inspection.by. Date - 7 Additional Comments: ``/2Z Applicant - Return all copies to: San Joaquin County-Public Health y Services, Environmental Health Permit/Se`rvidea" - 1601 E. Hazelton Ave.,, P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED <CK µ RECEIVED BY M DATE PERiMIT'NO. INFO - . Eli 1}24IREV.vnsl -� 3 ' O EH t1.2a t . C. 4 fl. -.. _.__ . �� b .TO,: O', b ..