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APPLICATION FOR PERMIT e ) gr'-1vZo iaQZfv`t'T' .Taa Rmc-e 6-G6 c�lu4L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A'1rEA rio,,:, OA 3g08i6kit ENVIRONMENTAL HEALTH DIVISION- _ INE)VSTCIZIA1- 9L.Vo. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 wee' "A 9.T69 I 2AMIT EXPIRES 1 YEAR FROM ,DATE ISSUED (91b) '371 -OLI3W (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. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .. Job Address 033 EAST 5L-C3 TS ,AVE, h jsJ-260-37 City r5�TAW Lot Size/Acreage Owner's Name '1.1.+1 Ftp IL L Address t�)_6G12NAD►140 "A CA___92110 Phone 7ty 366 Y091 _ 3(;-,63 OMEe— ►zu. 5�►c+r8 Contractor 0*r DR_ILJ_f�G. C.,�,Address RANCH{2 GC�VA t WL 9574? License No. SI l`tfZ�3 Phone 0jb 631--fsLk TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA Monitoring well DISTANCE TO NEAREST: a TANK t•ceT' SEWER LINES 100 Fit¢T DISPOSAL FLD, "'A PROP. LINE '''IA FOUNDATION Est AGRICULTURE WELL NAA OTHER WELL 25 T PITS/SUMPS '—A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -7- &�►FOTrzcHNttf�� t � yS ► MAx flfF-vT14 n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 6 "CS Dia. of Well Casing [1 Domestic/Private Ll Gravel Pack D Tracy Type of Casing Specifications I'] Public is Other n Delta Depth of Grout Seal tt H Tor? O"r !3—Ar RType of Grout t PXT oe J-n I I Irritation _Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing !Material b Depth Depth Piller Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION E I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence^ Commercial Other Number of living units: Number of Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg i No. Comet PKG. TREATMENT PLT. 0 ParMi �ay hal Method Distance to nearr 6r el �Q 1}l Property Line YYYY k � � 31d77MM 1,%2 LEACHING LINE Ct No. & Length off sti 1+ 't@d length/size FILTER BED ❑ Distance to nearest: Well pq ��_ Proppr� l (jC HEALTH SEPrI/IC;r s ffVV IRONMEN l AL H'RL7�i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an + 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 toy 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." Contractors 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 mut call for al r quire inspe tions. Complete drawing on reverse side. Signed X 770W Title: 5FAF-C— -E0 6r I N EER pate: R I7 ARTMENT USE ONLY Application Accepted by Date Area /v Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Aox 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFRECEIVED BY PATE PERMIT NO, /OC SH EN 17-241REV.t/Hs)V � Ma ` EH 14�2e L.�