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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 BOB 2009, STOCKTON, CA 95201 PSBMIT EBPIRES 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. 1 Job Address - 7E7 9. �� s"Ef'eGL City Toa Lot Size/Acreage Owners Nam Aill 10ea7►non Address PO. &x 3oa/0 Sfknr CA Phone I-8 Contracts Address ZSZ5 154A. MVeWPL VkA. License No. 5 2219 Phoney C-871L TYPE OF WELL/PUMP: NEW WELL - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Ve11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Velk2aff DISTANCE TO NEAREST: SEPTIC TANK ._/ _ SEWER LINES -Zjg�-- DISPOSAL FLO. Aid PROP. LINE Z,C FOUNDATION AGRICULTURE WELL —41- OTHER WELL 12• PITS/SUMPS Ada- INTENDED Ad6INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation S Dia. of Well Casing ❑ Domestic/Private Gravel Pack V Tracy Type of Casing V Cr Specifications Il Pubk n Other fl Delta Depth of Grout Seal (I Type of Grout A di Cr, ,4. I I Irrigation 2.1 Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Dons ❑ Type of Pump H.P. State Work Gorr Sealing Material a Depth - __s .._ Well Destruction O Well Diameter -' Depth Piller Material i Depth US TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of Swing units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to marest: Well Foundation Property Line LEACHING UNE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to newest: Well Foundation Property Line SEEPAGE PITS I I Depth Sita Number SUMPS LI Distance to newest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cattily 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 BanaW agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner ss to become subject to workman's compensation laws of California."Contraetoes hiring or sub-contracting signature card is the following:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion law of Cal forms." The applicant must call for SN requireA inspections. Complete drawing on rover"side. Signed VtnA U. lncCT-...IC_ Title: CA RCC Ain. 38322 Date: �• (My /990 �lFOR DEPARTMENT USE ONLY y Application Accepted by Date l t-/l l 9 0- _ Area w1 Pit or Grout Inspection by Date Final Inspection by Data/ Z- Additional Comments: Z "'W• ".L'V 4ALSfA," K Applicant - Return all copies to: San Joaquin County Public Health Services, Rrniromental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE NFO �7AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERM17'NO. !N 13-24 IREV.t,.srIN 1&28:471