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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) 7 Application is hereby made,to San Joaquin County for a permit to construct and/or instalwork 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 / //• y �i✓� City r OGlI"TG�" Lot Size/Acreage Owner's Name -��E kyA Y Address V�-./!fir kX.,J�TREET3" l/"tt*44-J4hone �s�' 671-316W1 O n , / 3.G G 3 0lra c C1r•.�urr� S• 6 , Contractor */ F,��/Ly/ikl� Cr o• Address VA . 4L License No. 45Phone TYPE OF WELL/PUMP: NEW WELL H WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring,Well 21 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE )`F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f � Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1001-1, Specifications r I'1 Public I_1 Other n Delta Depth of Grout Seal Type of Grout—Th"'.0 kz/"rAJ I I Irrigation YTZApprox. Depth I I Eastern Surface Seal Installed by �lf" /P/i t ;.,j G— CG Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter '/ Sealing Material & Depth Depth Y�l Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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 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 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 mus all for all require ' spec 'ons. Complete drawing on reverse side. Signed Title: Date: a7 FOR DEPARTMENT USE ONLY Application Accepted by Date �� r Pit or Grout Inspection by _ Date Final Inspection Date Additional Comments: Cod byj a 4W_ Applicant — Return all copies to: San Joaquin Co-4 Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK FEE INFO AMMOUNT DUE AMOUNT RRE�MITTED CASH CEIVED t Y 2DATE PERMIT*NO. . EM 13-24IREV.rin5l g7 m 90.0--' EH'A-20