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ENVIRONMENTAL HEALTH DIVISION 16 1 FHAZELTON AVE. , PHONE (209)468-3420 0. BOX 2009, STOCKTON, CA 95� RS YEAR FROM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in compliance vlth San Joaquin County ordinance No. 549 and 1862 and the Rules and RegulAtions of San Joaquin County Public Health Services. Job Address 1533 East Alpine Avenue city Storktnn Lot Size/Acreage Ernest Oneto ( 209) 463-996 Owner's Name rail Ma Garibaldi — Address 1 533 East Alpine Avenue Phone 209) 464-081 Contractor * Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION CY SYSTEM REPAIR ❑ OTHER O MonitoringWell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LHVEll BOrint FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ** 1'I Public 0 Other n Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material A Depth Depth Filler Material A Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is V available within 200 feet.) I r Installation will sena: Residence_ Commercial_ Other V Number of living units: _ Number o1 bedrooms Character of wil to a depth of 7 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line (S LEACHING LINE ❑ No. 8 Length of lines Total length/sire I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Watt Foundation Property Line DISPOSAL PONDS O I hereby canny 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 unifies 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 persons subject to workman's compensa. tion laws of California." The applicant must ca I III requjreA�sp ,ti Complete draw'mg o vane side. , Signed X fl "� Title: L.}W�—�O Date: L - I USE ONLY e ce /�-T — Applicatio oapted by Date s fFf Pit or Grout In edition,pri Date Final Inspection by Data /�y•� Additional Comm U *refer to " roundwater Assessment Re ort, Rea y-RPF" for details Appliciu(KN&yDWW1A6WALW: San Joaquin County Public Health FERNWISMICES Services, Favironizental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE ✓✓ IN AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE gPERMI7'N0. Hiii„s(REV.11.61 W 7— // // 2�Z