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w� s APPLICATION FOR PERMIT } x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES x ' � ; , 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 JAN 0 4 ZiS1 P O BOX 2009, STOCKTON, CA 95201 4 11,:;QNMENTAL HEALTH REMIT EXPIRES_ 1 YEAR FROM_DATE I§5UED }" tr�,rilT/ VICES (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��/ Seervices. /� Job Address l�� , +�vh ! r✓4 City 7fi 5N_�_ _ Lot Size/Acreage Owner's Name Urf mv-S FGLf 1dvii Address CQ � Q-K�U�G� Phone Contractor !� �ec Address GQ.Sa 9a�9! License No..1 ?'; Phone 211 37z z" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION r❑ SYSTEM REPAIR ❑ OTHER @f Mofit ring vWell DISTANCE TO NEAREST: SEPTIC TANK�� SEWER LINES 7ZAr DISPOSAL FLO. _` PROP.©INIE � FOUNDATION �.`3� AGRICULTURE WELLZ� OTHER WELL b PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A4L S'a4o v;i lord ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation erre Dia. of Wefl Casing FI Domestic/Private ❑ Gravel Pack 9-Tracy Type of Casing Specifications — Public iither n Delta Depth of Grout Seal s/ Type of Grout I Irrigation , Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State ork, one _ Well Destruction 0 Well Diameter Sealing Material A Depth �e / 2W Depth Filler Material A Depth ct__7 ' — 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewar is available within 200 feet.) Installation will serve: Residence_._,_ Commercial T._,.. Other Number of living units: Number of bedrooms �l Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t ) SEEPAGE PITS 1 1 Depth Size Number V �1 SUMPS D 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 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 persons subject to workman's compensa- tion laws of California." The applicant must callrfbr all required inspections. Complete drawing on reverse side. Signed X e4 "' Title: koeo 7 ZZ Date: 12-31' ?0 �}yy FOR.DEPAfi MENT USE ONL GY Gj Application Accepted by f 1 - _ Date__!;_,P. l 1. Area LL Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: U, Applicant - Return all copies to: Ban J in County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'ND. r . EH 13-2 (REV.1rnS1 9 .—� .I� / 't'J'e'3371 `�' 'i! EH