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APPLICATION FOR PERMIT JOAQUIN COUNTY PUBLIC HEALZ SERVICES ...i ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 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 L/03 �o / C/u ✓� City S .E1v-� Lot Size/Acreage Q. 9 Qe—es Owner's Name 0,r 0, — � ��✓��✓ Address tesla/ «t '7-�?,ee-o hp,n —T� �yrd- c�c.�•� �fv� -''� 3Go07C-S Contracts T �D Address F:�--, fonst 6a 93335 License No.sYY907 Phone !� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O CTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRc�vapw+�1, ER W Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC TANK AJ Iq SEWER LINES G So OISP LD. �� PROP. LINE -- IO FOUNDATION Z � AGRICULTURE WELL-2-,L0.a� OTHER WELGi 0 ' PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS %7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public CI Other n Delta Depth of Grout Seal Type of Grout � M I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by �� ? �+ - To^yea _- Repair Work Done U Type of Pump H.P. Stats Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth 47Skg !� AI Depth Filler Material 3 Depth f- 6� H� �1 -7 �� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available withi 200 feet.) r I\tallation ill serve: Residence Commercial Other ving units: Num r f bedrooms soil to a depth of 3 feet: Water to le pth SE ❑ Type/Mfg apo ity No. Com art nts PKENT PLT.❑ Method o Di al Distance to Barest: Well Found tion Property Line t LEACHING LIN ❑ No. & Lengtof lines otal length/size FILTER BED ❑ Distance to n rest: Well Founds on Property Line ` SEEPAGE PITS 1 Depth Sire Numbs `, uu .Ion ,or 1V rD DISPOSAL PONDS ❑ n A I hereby certify that 1 have prepared this application and that the work will be done in accordance with San JoaquindinanCeal�lyl�� 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 IG��ihYl1'not employ any person in such manner as to become subject to workman's compensation laws of California." Contractli) P ting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 's ly �-- !z� Signed �y• Title: i �� Date: /-71-7 q4,:,,FOIR DEPARTMENT USE ONLY / —`9 !� Application Accepted by Date Area ✓ �1 Pit or Grout Inspection by Date Z- -I Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin 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 CASH RECEIVED BY OATE PERMIT NO. EM,3.I.IrtEV.,,"e1Via ?1' S'9 X061 q- EM .b26 L I 1