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APPLICATION FOR PERMIT t t SALT JOAQUIN COUNTY PUBLIC IiEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. IIAZEL`i'ON AVE. , PRONE (209)468-3420 ' P 0 BOX 2009, STOCKTON, CA 95201 URMIT EXPIRES 1 YEAR FROM DAA'£._ 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 `] 6-0 �/ ,1 City�?C�� Lot Size/Acreage � )J Ov,rner's Name �-)t„r,. �6 �/�! AddressPhone �J�-� � �+1 Contractors �,' ! G 1� Address _ '. l / ! License No Phone Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f 1 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION D SYSTEM RF,PAIA O OTHER O Monitoring Well k DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL MTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom 0 Manteca Dia: of Welt.Excavation Dia. of Well Casing Cl Domestic/Private C1 Gravel Pack C7 Tracy: Type of Casing Specifications- I'] Public I.1 Other f-i Delta Oepth'of•'Grout Seat Type of Grout,_, I I Ir6tjation —.Approx. Depth I I Eastern 501{d Ge Seal Installed by Repair Work Done 0 Type of Pump H.P. — Stats Work Done: Depth S D i t M ling Material ep Weil Destruction O 11411E Diameter Sea , Depth Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION REP•AIRIADOITION I I DESI"RUCTION i I tNo septic system permitted if public sewer is available within 200 feetA �� Installation will serve: Residence /,�Comrnercial Oti>er Number of living units: Number of bedrooms +,� J Character of roil to a depth of 3 feet. c ?>�/9� _/� %2{ __.Water table depth 5EP71G TANK ❑ Type/Mfg 24 Z Capacity— No. Compartments ` PKG. TREATMENT PLT. ❑ -D, tY' X. Method of Disposal Distance to nearest: Well _r,�• � Foundation .-�► �.r�_ {property Line � LEACHING LINE No. & Length of lines ___. _- � _ Total length/sixe— a FILTER BED { I Distance to nearest: Well��lD �_ Foundation Property Line �J SEEPAGE PITS I I Depth Sira��— — Nunib9r_ SUMPS LI Distance to nemrest: Well ` Foundatioh___ Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this appficaiion 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 lavas 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 shaH employ persons subject to workman's compensa- tion Iaws of California." The applicant must call for all equiredspection Complete drawing on reverse side. 4 x,. L� Signed X r Tilio: _ � �-"Z.[2�� Date: FOR DEP ARTNi Ia NT USE ONLY 1 Application Accepted by �s__-_4 _._, Date Area ��. �Jr Pit or Grout Inspection by Date ,..�___ Final Insprr•tian uy°-�:�- Additional. Comments: ------------ -_�------ _ _ __ __ - Applicant - Return all copies to. San J'o�s;i+wiu County Pllb1J-c-lif:aitfi Services, Environmental health Pernsi't/Services 1601 R. Hazeltou Ave., P.0 Box 2009,. Stockton, CA 95201 FEEC� AMOUNT DUE AMOUNT REMITTED "CASHa�RECEWFO fly � DATE PERMII'NO. INFO _ ay DATE .____.._.._.� �..�...�_........._ + EH 13.24 ff1�V. /a5l / EH A-213 - ""�CPQ w•��c.- .� - r if PLATE 19