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APPLICATION FOR PERMIT • t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. Thie 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. H 22 -- rn A g- Job Address 1}1D1 fw&- 1k,I{1iyet City Lot Size/Acreage N aDia'jO Owner's Name aI/rIDC�p�Q"`.M Address P�' f6X 5155 1 n ItJ N0n., l./1 Phone(•�D)a77__�—�� II pp&� 9457 SS 639 Phon 7� V q_'1 Contractor vaA rl I II Address 6 License No. _6 TYPE OF WELL/PUMP: NEW WELL A WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER V Montt rq ingE•Well DISTANCE TO NEAREST: SEPTIC TANK _ IT SEWER LINES N�— DISPOSAL FLD. PROP. LINEbcir—pCt1 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial O Opan Bottom El Manteca Dia. of Well Escavatiyn hDia. of Well Casing Ih _ I I Domestic/Private Gravel Pack El Tracy Type of Casing , 4DPC-"PC` Specifications C ,� I'I Public ISI Other ❑ Delta Depth of Grout Seal u- Type of Grout 1 I litigation _Approa. Dept I I Eastern Surface Saul Installed h, Driller- Repair ril {.-Repair Work Dona ❑ Type of Pump N H.P, $tatW D mt 1 (�1,1Q 111 Sealing Peter al i Depth N t "_ Well Destruction ❑ Well Diameter CA7ry17 S� )( Destruction Depth ,rJ Filler Material L Depth I 3D TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permitted it public sewer is available within 200 feet.1 Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line_ LEACHING LINE Ll No. 6 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size __ Number SUMPS LI Distance to nearest: Well Foundation__ Property Line DISPOSAL PONDS ❑ I hereby certily, 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 sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa tion laws of California." The applicant mustcallfor at r uire/d�inspections, Complete drawing on reverse side. Signed % � l il/ a4114' (f-ttl J Title: ao e,- /t'E2.,.a.o tom✓ Date: 80 FOR DEPARTMENT USE ONLY �✓ v� Application Accepted by Date �/-2.93 Area .. Pit or Grout Inspection by/I 1' 1 Data Final Inspection by Date m Additional Comems: '2_ VF -- Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO FEE AMOUNT DUE CASN . EN 3-34IRfV.1/nei , -- X93 �(- 43- 8 EH IbM