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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-35420 . P O BOX 2009, STOCKTON, CA 95201 �1 XP RES 1 YEAR FROM DAE ISSUED )97,7 (Complete in Triplicate) f 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 coslPliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules-and Regulations of San [ Joaquin County Public Health services. S ! • C' t Job Address . plz. (v.r�C t f City.l- Lot Size/Acreage i} �• Owner's Name 4C)"Gtf� ~i -� ( !` � `� ` . Address Phone f Contractor P ltr.� Ott \�.(� Address l �� f�i�� r l43 -.-... '' tri I-}�� License N11; Phone /• �r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Li PUMP INSTALLATiON.❑ xSYSTEM REPAIR-❑ OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial D Open Bottom 0 Manteca Dia. of Well,Excavation l !� f ---L� = Dia. of WeG Casing f= 'C�Domestic/Private Gravel Pack ❑ Tracy -Casing' Z" y 4-ype of Specifications I I'1 Public 1-1 Other n Delta Depth of Grout Seal R. . Type of Grout f' J i I Irrigation —_Approx. Depth I I Eastern Surface Seal installed by 7-0 f"' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth i Depth Filler Material & Depth f f TYPE OF SEPTIC WORK: NEW INSTALLATION 11 "REPAIR/ADDITION i I DESTRUCTION 1,1 lNo septic'system permitted if public sewer is '-available within 200 feet.) { ,� Installation will serve: Residence�f Commercial.._. Other Number of living units: Number of bedrooms %^ i Character of soil to a depth of 3 feet: r o # 11Vafer table depth 1 SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ +4,: I Method of Disposal Distance to nearest: Well Foundationr�' property Line Ilk LEACHING LINE ❑ No. & Length of linesTotal {ength/siie FILTER BED ❑ Distance to nearest. Well Foundation Properly Line SEEPAGE PITS 1 1 r Depth ` Size , Number ` SUMPS Ct Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l w + 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 a 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 t employ any person in such manner as to become subject to workman's compensation taws 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." The applicant roust call for required inspections. Complete drawing on reverse side, Signed 7 !'t:� ': ,1 L' fr '� �, it-.. .I �4 a y Title: C t o r -~"` Date: -7 OR DEPARTMENT USE ONLY Application Accepted by Date y � Area Pit or ut Inspection by Date Final Inspection by CK-� — a . vv Oats s� a Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA' 95201 i FEE OUNT DUE IAPAOUNT REMITTED t INFOC[ASS.Hp� RECEIVED BY 41 iEo PERMIT'NO. r . EH 13-1t IAEV.FiHs� .Q� Lf(1 f V•' �V EH Zl-ie