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APPLICATION FOR PER r ) SAN JOA �OUNTY PUBLIC HEALTH SERVICES NMENTAL HEALTH DIVISION HAZRLTON AVE. PHONE (209)468--342 ->(a O BOX 2009, STCICKTON, CA 95201 F)Y I EXPIRES 1 YEAR FROM DATE SSUED (Complete in Triplicate) Applicn ereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coWliance with San Joaquin County Ordina ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 61 City { Lot Size/Acreage Owner's Name 4wo awa_ s( -o Address �Q� �' (1 f � � Phone ;I— f-b 0Gx '72i� 94-5-16,5_5 Contractor t 1 Y Address I-fac lrl �� License No. 3 j�-3/5 Phane_ • TYPE OF WELL/PUMP: NEW INELL)ZI WELL REPL CEMENT ❑ DESTRUCTION 9 Out of Service Well 1-1 PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring'Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a- DISPOSAL FLO._l* PROP. LINE 5 L FOUNDATION S� AGRICULTURE WELL -IV4 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationJ/ 'j ,SFS�� Dia. of Well Casing ` '4? f f I Domestic/Private A Gravel Pack ❑ Tracy Type of Casing /��O _ 'YG Specifications f 1'I Public 1:1 Other 11 Delta Depth p Grout Seal —(e5 _ Type of Grout l v:i?, I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by CC?Ik'i1f C Repair Work Done ❑ Type of Pump H.P. _ State Work Done — Weft Destruction O Well Diameter `�` J L" Sealing Hateri 1 & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FiLTER BED Cl Distance to nearest: Well Foun ation Property Line SEEPAGE PITS 11 Depth Sire . Number SUMPS LI Distance to nearest: Well Foundation rn _ Property Line - DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be cone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Horne owner or licensed agent's signature certifies the following: "I certify that n the periorrnanre 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 applical3timust call for all required I spections. Complete drawing on revere side. Signed Title: LIQ "' _ Date: 6ucL}!ye 'jk,/ , FOR DEPARTMEN r USE ONLY 1 3, Application Accepted by ! 7 f / Date Q Area ` _ Pit o �iro Inspection by , _ Date {,�z�� 23inal Inspection by Date r . Additional Comments: fir`'► 5 Ke� Applicant - Return all copies o: San Joaquin County Public Health Services, Environmental Health Permit/Servicers 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT DUE 'AMOUNT REMITTED `CASs RECEIVED BY DATE �P'}ERMIT'NO.- • FH 13 24 IREV.1/9 Sr