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APPLICATION FOR PERMIT l A_2 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 _ P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES Y R R M 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 Bo 119 and 1862 and the Rules and Regulations of Ban Joaquin County �Pu/blic Health Services �f Jab Address ��/;I �? di4� G9�iP47 X09V City�9M,oL Lot Size/Acreage Owner s Name A!0 144MAl L D /40*B ZO Address f-444 6—:— aA1c_c Woz— � C-s-� Contractor kieEsr IAzMq(:. _Address 3z� FiT �ELq�� S/ License No5-5y:7;72 . Phone ' TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service dell Cl PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER OLSC/`n ��ng ll C2 DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrrai ❑ Open Bottom ❑ Manteca Dia of Well Excavation i<rN Cr Dia of Well Casing [I Domestic/Private 0 Gravel Pack © Tracy Type of Casing Specifications I Public dd Other Mr-IAlGL n Delta Depth of Grout Seal Al ,# Type of Grout I I Irrigdtion 19ti'Approx Depth i I Eastern Surface Seal Installed by 6v 1.11fS I- N T- Repair Work Done U Type of Pump H P State Work Done ' Well Destruction ❑ Well Diameter Sasling Material, i Depth 4=�rG ",y f Tb%�� DGYrN 76�-Glfd Depth Filler Material, i Depth TYPE: OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is evadable within 200 feet I 10 Installation will serve Residence— Commercial_ Other Number of living unite 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 0 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ filo flr Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 subcontracting signature ' certifies the following I certify that in the performance of the work for which this permit is issued I shall employ parsons subject to workman s compensa tion laws of California " The applicant m at call for all required inspections Complete drawing on reverse side / �iFrAlraA 6 ern co % Date / �'/� Srgnad � Title - C1Vo� uV"P-0 ,.I 0-"-7-f C— O DEPARTMENT USE ONLY Application Accepted by r' Datalrlr- Area Pit or Grout Inspection by Data Final Inspection by Date dditional Comments , Applic%at - Return all copies to. San Joaquin County Public Health cirt.0 y Services. lbvironmeatal Health Permit/Services II Q 1601 E Hsselton Ave., P 0 Box 2009. Stockton. CA 95201 l/Yr FEE AMOUNT DUE AMOUNT REMITTED CK a RECEIVED By DATE PERMIT NO INFO CASH 13-24(01EV I I it sk 017 ' •yjV /v 72 Y H 426