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• APPLICATION FOR PERMITS SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. RAZELTON 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. I _ Job Address �`7-Di f4:l i1G z'11A°YIUPi City✓J�/� —(��t size/Acreage N �1�� Owner's Name IS Dml`^—p�Q' � Address M ODk 5155-,1 Vlp ,I••'-' yn CA PhGone(�D •fa.�n7_�-7 2J01 II CA_1`1571 SO 63/ Phon lvl 7`q_-I Contractor Doo r1 I II Address RD. sox is (cense No. TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEMREPAIR ❑ OTHER V4�M,°ni„t r, Sngr,Wel IF A an t DISTANCE TO NEAREST: SEPTIC TANK �A SEWER LINES N DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS in Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation h• Dia. of Well Casing Cl Domestic/Private Ix Gravel Pack ❑ Tracy Type of Casing .L C= Specifications , I'I Public fl Other fl Delta Depth of Grout Seal D- Type of Grout 1 1 Irrigation _Approx. Dept I I Eastern Surface Seal Installed by 1)r-1J 1 -- Repair Work Done ❑ Type of Pump H A H.P. $laatec W D rte Well Destruction ❑ Well Diameter f�1ID in Sealing Material i Depth tf T S/U )(`f u L II Depth Filler Material 6 Depth '30 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal <, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size _t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number I SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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�d- rules and regulations of the San Joaquin County t 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 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 for all r/�Iuueedd inspection . Complete),drawing on reverse side. //� Signed X_( �rC W!-_ J Title: �y0 'e��' /�E�.eo 1.1- Date: FOR DEPARTMENT USE ONLY A �✓ J Application Accepted by Date Area Pit or Grout Inspection by `' I ate '31 Final Inspection by Date Additional Comments: 22�ED Applicant - Return all copies to: Ban Joaquin County Public Health Services, Environmental Hqalth Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17 N0. NFO CASH r ER 12.24 IREV.1/851 /3 • q3- S EH; .26