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APPLICATION FOR PERMI SAN JOAQUIN OlDM71-4PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION co 1601 E. HAZELTON 200 AVE. , PHONE (2095201 42 P P O BOR 2009, STOCHTON, 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. n�z Job Address 1177-:5,'o ��7-:5� Lor /1W1 51 �r -- Cit�`��0� Lot Size/Acreage �,J Owner's Nam ! Name z /�/E�o—a v��y Uz/� rft Address J O — Phon�N /_ Conl,actor[meUMf ( � J��N dress �`DAV Gf 0AJ._ 1v License No. �P9113 Phone '646"54 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR LIOTHER ❑ Monitoring well x DISTANCE TO NEAREST: SEPTIC TANK7'Z66Clt SEWER LINES NT DISPOSAL FLD. PROP. LINE4-1"/ FOUNDATION WNA AGRICULTURE WELLs99LL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS (l Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation�-- Die. of Well Casing )Q Domestic/Private ¢(Gravel Pack ❑ Tracy Type of Casing � CV Specifications Il Public ( I Other fl Delta Depth of Grout Seal Type of Gmou Y/Yt q I I Irrigation 42D Approx. Depth I I Eastern Surface Seal Installed by dZrLLE.e3 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material a Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other 1 Number of living units: Number of bedrooms �Y1 Character of soR 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 Ll No. a Length of lines Total lehgth/size FILTER BED ❑ Distance to nearest: Well __ Foundation Property Line SEEPAGE PITS 11 Depth Siva 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 S 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 of sub-contracting signature p./�� certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compenza V ti of California," T e so nt m all 1 r If required Inspections. Complete drawing o verse side. , Sig Title: Date: FOR EPARTMENT USE ONI_ �yQ/}Vpq �_-/a / A ion Accepted by Date� 1— Area 42 / r Pit or Grout Impaction by �i // Daatte Z O Final Inspection by L t 5�7�..L, L Date Additional Comments: -_� /C/ l s71?2 lc-o� a-TJ- lazlto�, D/ Applicant - Return all copies toe 6an Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Haxelton Ave., P x 2009, Stockton, CA 95201 FEE AMOUNT DUE MOUNT REMITTED RECEIVED BY DATE PEA 17 NO. INFO /� y/� (G�.ty� Q'l tlr, . EH i1.3r IaEV.,ren, / TI fes` 7—IV /� /V_ O EH:sa!