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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, STOCSTON, CA 95201 E%P RES 1. YEAR EROM DAIrk ISEUED � I (Complete in Triplicate) SEP 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 Count Ordinance No. 549 and 1862 and the Rules and Re Joaquin County Public Health Services. y ;;Ir n Job Address 5:35 3 R 1- DCC_443CrZ- /t ieny4ue City TSAC.�:e -_ Lot Size/Acreage S ,s 10C,90 Rom AuE Owner's NameY ELl-C�t.1J �R�CCsGt S'�_S�04Rddress QQC-YL ,M, PAf1+K K&W 6" Phone C S�cr Twu, CAS ContractorS(�LtR+JIm Address Zf3ZS E. A' YRTt_.E License No.512'Z(o$_59phone F ❑ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ad Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR C_-] ..OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK A p'+llt; A SEWER LINES 666e t DISPOSAL"FLD.Qlta"PROP. LINE MFT. L/]' FOUNDATION N0111E�- AGRICULTURE WELL OTHER WELL PETS/SUMPS Na^tt jr " INTENDED USE TYPE OF WELL '?ROBLEM AREA CONSTRUCTION-SPECIFICATIONS n Industria! O Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 411 fa Domestic/Private ❑ Gravel Pack fry Tracy Type of Casing I?YC Specifications5�'t6 � I'1 Public # 1-1 Other 1-7 Delta Depth of Grout Seal _____ F�_-- _ Type of Grout �S a 1 Ct�tst i I I Irrigation ..,� Approx.'Depth I 1 Eastern Surface Seal Installed by 1 Rc✓n�t� __ _ R _' Repair Wok Done 0 Type of Pump H.P. State Work Done - Well Destruction W!III'Diameter r� r Sealing Material & Depth ,rE n-loP� pi Depth lg'.{,? fir,; Filler Material & Depth-lS/tnJO G IS-5 �-{- 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.I r n Installation will serve:: Residence. Commercial_ Other ,-j- Number of diving units: Nui berf of bedrooms Character.0460 to a depth of 3 feet: Water table depth SEPTIC TANK,.,: ❑ Type/Mfg .1 ' Capacity No. Compartments �PKG. TREATMENT PLT. El v;S �.. 1k v'% .� ;-� Method of Disposal ' f" Distance to nearest: Vilell Foundation- Property Line (/y LEACHING LINE 0 No:&'Length of lines r Total length'/size FILTER BED C1 Distance to'nearest: Well Foundation- — - - Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS, 1f l ,d CI Distance to'nearest: Well r Foundation Property Line C DISPOSAL PONDS ❑ I hereby certify that1 have piapaied thisapplication a7nd_that1he York—Will done in_accordance with San Joaquin_county_ordinances;_state-taws,and.,,,..,.,,,,e, rules and regulations of the San Joaquin county Home owner or licensed ageni's signatu"re certifies the following: -'I cartity 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." I The applicant must call for all required insPections. Complete drawing on reverse side. Signed Title:,5�tow% Baogm - Copc_Ur�6117_ Date: Q8,�.Z9T_ _ R P ENT USE'ONLY Application Accepted by Data Area Pit or Grout Inspection by Date _Final Inspecti6n ~Date/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health rServices, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH Cy RECEIVED BY DATE ,PyERMIT'NO. . EH t3-24IM,i/Rs1 �(�' DL7 /DCS s1e EH 14.26 `� ! (✓ //�� Gtr/ c