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i Ii r APPLICATION FOR PERMIT '^ � f : (J,J� SAN JVAQUIN COUNTY PIIBLIC HEALTH SfikVICfiS f E ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201Apr ' n eD 14 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rRec ? (Complete in Triplicate) r` i�V �CNr4 �n Application is hereby made,to'[San Joaquin County for a permit to construct and/or install the work herein dez3ek'oed_� 4ijy application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatloi6�& San Joaquin]County Public •�H1/ealth Services. Z32 > �^ I'�-`f� Job Address ( Z320 �/v� ' Qof-o- �I Ci't/y(�(/fk+01 Loot size/Acreage Owner's Name " 611 SOI I CO. Address,,` "' "dn }r'O 7�0- 141116"ll, (A 1Z4h1neCC00Z�y3'� Q(' t Ra5red1e_6f ' Contractor 1�-'- CXO I�ii�1 Address 1790 UrrMch 5,A-3, 956zd' License No. 265556 Phone( �)713-1733 TYPE OF iWELL/PUMP: � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ •PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well 0 DISTANCE TO NEAREST:!SEPTIC TANK SEWER,LINES DISPOSAL FLO. PROP. LINE fi 'FOUNDATION- AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑.—Manteca Dia. of Well Excavation 42, Dia. of Well Casing n Domestic/Private ❑ Gravel[Pack ❑ Tracy _ Type of Casing NO& Specifications D1 (Iw I'I Public I (-1Other l n Delta— Depth of Grout Seal `I-' Typo of Gro e I Irrigation App ax. Depth XEastem Surface Seal Installed by r`, Soil 6,r; '6 20' 0 1 Repair Work Done U ,Type of Pump H.P. State Work Done_ r) ] k 1 Sealing Material & Depth G-0.!ir 'ZV �(/V11 Well Destruction ❑ Well Diameter _ C' t � i Depth t Filler Material & Depth &CD-Jt" T•\`a ZJJ''h SyE4o TYPE OF{SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.] Ins[allanton will serve:1 Residence I'_ Commercial_ Other � Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg /�'acio. Compartments n PKG. TREATMENT PLT. ❑ I� �1`= Line of Disposal 1 Distance to nearest: Well Fo at 11JLPro rty Line LEACHING LINE- ❑ No &,Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth` Site Number SUMPS LI Distance to nearest: Well Foundation Property Line r ,1 DISPOSAL PONDS ' ❑ 1 hereby certify that 1 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 p Y an y person in such manner as to become subject to workmen'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 must call } I re ireY!Qnspeotions. Complete drawing on reverse side. f� l Signed K Title: 6 Date: yy+ TMENT USE ONLY ! I ApplicationaAccepted by _ Date L3 g� a L� 1 S Pit or Grout Inspection by Date Final Inspection Date al �] Additional'Commen ts: Applicant - Return &11.copies to: San Joaquin County Public Health i ' Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 kFEE I INFO AMOUNT DUE AMOUNT REMITTTE�D} CASHz RECEIVED BY DATE q (+.PEfl MIT'NO(. III1J , E/3--24 1REV.i/n5i F", C Qv � /SfJ jL'_. �/ lOEm rr'JJJJ 1 S