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I- APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to Sm 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. .[..,,, Job Address 41 oq- /Pa/�lC / /ye /� City •�G��"r"r- Lot Size/Acreage "' 30,oca 4. Owner's Name VA'OCf'r '-^� ' ' Address �0. /'.X J' s`�� C4 Phone5l0 Contractor v"e5+"X Address 0• � t-✓ry License No. 15,3'11 q� Phone�� TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ nR Well ,1, Va NIc.G.C. DISTANCE TO NEAREST: SEPTIC TANK 'vim SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /�•LS /w' Dia. of Well Casing 4 C-.l Domestic/Private ;K Gravel Pack C3 `7d A Tracy Type of Casing sek Specifications I'I Public ✓"p,(�t(�'' I I Other r Delta Depth of Grout Seal /o'ZO Type of Grout Ne&rC",t¢wf' Irngatlon w _.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump � H.P. State Work Done_ Well Destruction C] Well Diameter r Sealing Material & Depth /9-2o jv St..•f.--�a— S Depth TZ t�•Filler Material i Depth eo- rA•VC,Q —T '�`• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I INo septic system permitted It public sewer is available within 200 feet.) Installation will some: 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI 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 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 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 applic ust call for at requ'rr, inspections. Complete drawing on reverse side. ,t' p Signed I Title: S fi I Y,4��J� Ie: 3/J /f 2— FOR DEPARTMENT USE ONLY Application Accepted by Date 3 5 Area W Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �-T Applicant - Return all copies to: San Joaquin County Public Health ,r q, Oro Services, Environmental Health Permit/Services /v 1601 E. Razelton Ave., P 0 Box 20 tockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 11 EIVED BY DATE PERMIT NO. INFO /],, CASH • EM li 24(REV.r/x SI � �i�(/ 7 1(}/• EM'4.26 r,7