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+ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 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 ' ' . CityLot Size/Acreage t �.:,.�_ Vit"` ��r 7ti Owner's NameAddress Phone ;" --a � t Conlraclor is •.. , 'I., __Address L ?- E _.ink )ll License No.',l - :� ?r,2,,---'K Phone�7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C_1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK /C3{ ,' SEWER LINES DISPOSAL FLO. PROP. LINE_ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial Ev6pen Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing E4I omestic/Private U Gravel Pack a Tracy Type of Casing=*" Specifications I'I Public is Other Cl Delta Depth of Grout Seal Type of Grout r I I Irrigation _.Approx. Depth I 1 Eastern Surface 5eu! Installed `�`� 'r-s e=s i M Repair Work Done LJ Type of Pump tj t� H.P. Work Done Well Destruction 13 Well Diameter Sealing Material & Depth t Depth Filler Materiel & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ '-Commercial—.-..• Other ~. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water labia depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C7 Y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED 11 Distance to nearest: Well % Foundation Property Line SEEPAGE PITS IJ Depth Size Number Ir SUMPS L! Distance to nearest: Well Fouridai_ion Property Line DISPOSAL PONDS ❑ hereby certiN-that ll hav6 prepared this application and that the work rk will be done i_n accordancewith.San Joaquin county oidinances;state-laws,and rules andiiieulatid-n of-the Sarni Joaquin County Home owner or licensed agent's signature certifies the following: 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 sublect'to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the following: "I certify that in the peirformance of the work for which this permit is issued, 1 shill�ploy persons subjectt o workman' pompensa- rion laws of California." �a `p" l L-t The applicant must call for .I required inspections. Complete drawing an reverse side. � � S—// Signed X t Title: Data: / OR DEPARTMENT USE ONLY k --9� Application Accepted by Datee� Area Pit or Grout Inspection by i � �ate l I Zb' Final Inspection byi_. �M �� Date Additional Comments: 0 1 ` ael w a s U � Applicant - Return all copies to: San Joaquin County Public Health" ° R d,JQ`Q`` Services, Environmental Health Permit/Services 10e0-1A 11 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 J FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY !NF CASH DATE PERMIT NO. + EM 13.24{REV.I i n 51 {� �} y, / �f f EH"s4-28 L3t CJ t� ,� 5 1 �, — `"[ �b OvrP / Lt/ 9v — 2L��