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Fr e-10 , APPLICATION FOR PERMIT „ • K SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 REMIT EXPIRES 1 YEAR FROM DATE ISSUED I ;I (Complete in' Txiplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the Bork 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. I Job Address uta City. :S+pr_c4rn Lot Size/Acreage -3-1-7-ix t408, Owner's Name C4r.VfeAA USA, Tv,c. _ Address _R±__Qna..a Roc Zs'y Phone t Contractor CxeL14-ac_6_ Address License No. G7%- Phone lnS�- TYPE OF WELL/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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ll� ' pia. of Well Casing El Domestic/Private ❑ Gravel Pack `❑ Tracy Type of Casing Pyc� Specifications ('1 Public Other t�lt�tke`nn� .171 Delta Depth of Grout Seal -601 Type of Grout.- dlra�Ienu^4 I I Irrigation qb`Approx. Depth I I Eastern Suriace Seal Installed by E)rc:cl't'Cc Repair Work Done Q Type of Pump H.P. State Work Done .i' Sealing Material A Depth � Well Destruction ❑ Well Diameter y�-� � � Depth Filler Material t Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is N 1 available within.206 feal.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line t LEACHING LINE YA 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest." Well Foundation Property Line SEEPAGE PITS 1/� 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line F DISPOSAL PONDS ❑ I I hereby certify 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 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 laws of California." Contractor's hiring or subcontracting signature canifies 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." l The applicant must call 10jr all required inspections. Complete drawing on reverse side. Signed) Title: -,'�' b-f e% ?� Date: FOR DEPARTMENT USE ONLY p Application Accepted by h, _ `"r Date Area Pit or Grout Inspection by Date Final Inspection b Date �•`t"'71 Additional Comments.- Applicant omments: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 INFO AMOUN111 FEET DUE AMOUNT REMITTErD CASH RECEIVED BY DATE PERM�`I'T'NO".� 4 . fM 1,-2244[ACV.1/n$I C I � co t ' "}`i 1 � €:.5C3:eH `