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iA APPLICATION FOR PERMIT ter_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOC TON, CA 95201 PEJRMIX EXPIRES 1_-YEAR FROM DATE IOUED (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. (�.�r1it?f- Job Address i r'� i � ��1 �1n 1' 11�� _ - City ' Lot Size/Acreage - 1i , f q f �f Owner's Name f�T::t tL}" ON i: Address�� wtv, ',.A '� �}r✓ Phond�^L-cl ;J t _�?� Contractod`j? E �f .V Address tc - �, f., . !'C�+� s1 _ ,d � f~ .. %r,C License No.t_ r� Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION N Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f--I Industrial 0 Open Bottom O Manteca Dia. of We Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public fa Other fl Delta Depth of G out Seal Type of Grout "f I l Irrigation —Approx. Depth I I Eastern Surface Sad installed by Repair Work Done v Type of Pump H:P. State Work Done C Wel! Destruction ` Well Diameter 2-_i.+�LL. Sealing Materia-1 Depth. irAt Z.5, I x t, Lft,,4 edkf k+ � G rfi� ' Depth_ 5O PGtt` Piller Material 4 Depth LLC '1�ryC - TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION i I DESTRUCTION l I Wo septic system permitted if public sewer is available within 200 feat.) Installation will serve: Residence Commercial— Other r` Number of living units: Number of bedrooms Character of&oil to a depth of 3 feet: Water table depth r SEPTIC TANK 0 Type/Mfg Ca city No. Compartments PKG, TREATMENT PLT, ❑ Method of Disposal { Distance to nearest: Well Foundali n Property Line j LEACHING LINE ❑ No. & Length of lines Total length/size r i FILTER BED ❑ Distance to nearest. Well Foundaton Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be donD 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 compensaii n 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 parmit is issued, i shall employ persons subject to workman's compensa- tion laws of California." t The apptican Lust call for all 31�,ed-inspections. Complete drawing on reverse ide. / /�� Signed x_ l!c c�G- • al cy Title: /11t , 1ff' /�/,i%, ,t s Date: V FOR DEPARTMENT LISE ONLY Application Accepted by ljkDate Z/71/9 Z Area Pit or Grout Inspection by _ --- Date Fin I Inspection by .. ��t�t1J-�C Date Additional Comments: M" M w )Lf tv Z. - Applicant - Return all copies to: San Joaquin County Public Healt Services, Environmental Health ermit/Services 1601 E. Hazelton Ave., P 0 Box 9. Stockton, CA 95201 FEE AMOUNT OVE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO J . EH 13-24{REEV.1/N5) �o 6 0 rY�S , 1< 7/�./R U 4Z--5/2� EH 74.20