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1601 F, HAZELTON AVE. , PHONE (209)41`t?-3420 �0 BOX 2009, STOC%TON, CA 954 s PERMIT EXPIRES 1 YEAR FROM 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 No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address j'^-'c6 �` /fir - �V�'- City � 4�N Lot Size/Acreage F6;z5"6-)- Ave. . y 3 r-j' F'/,, r� ot- Owner'sName L rQl:-J&n G . _ TM Address �uc,ur Ucr k'r N.y;, . �'� rni S . Phone Contracts '\ Iy 4 I Address License No. Phone TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. Soil bori.,LINE __ 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications ' I'I Public 17 Other n Delta Depth of Grout Seal Type of Grout I I In'gauon _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. Slats Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth _ Depth Filler Material i Depth Iv` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted it pubfic sewer is W • available within 200 feet.) Installation will some: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth C 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal u Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 6 Length of lines Total length/size FILTER BED ClDistance to nearest: Well Foundation Property Line 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, and rules and regulations of the San Joaquin County Home owner or licensed agent's si nature certifies the following: '1 certif that in the I 9 g: ' V performance of the work for which this permit is issued, 1 shell not i 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: 1 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." ' Theapplicant ust R lOr all required inspections. Complete drawing on fever" side. II _ q Signed X Title:L'z�`'`� Date: 2 j F DEP ENT USE ONLY !/ q Application Accepted by � ^Lc%?!!6% Date / n// Area Pit of Grout Inspection by nDate Final Inspection by{.^T Additional Comments: ` re�a.�, (r r � LI<Sccc ��G"L k, ✓±�.. -�� Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Ratelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED Kt FEE CASH RECEIVED BYFOATE PERM17'NO. ,::mlaFy.,,.m, EM177I5