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APPLICATION FOR PERI' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$- 2 P O BOX 2009, ST KTON, CA 95201 EXPIRES 1 YEAR FROM DATE ED o (Complete its 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 Ordina ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 50/ lrtfl Lal LU City Lot Size/Acreage -2 -A .5 f3 Ii Owner's Name 7 illi LtU 7/ � w Address ) 1-14 k- l - yqV"3 Phone Y 13 -J L_-) e � �7r1 tI'1 Yr� 'jl4---- Contractor W [�"`�!r1 Address ' '� &X /2 �n (4 License No. 3 � -3 L15 Phone TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT C) DESTRUCTION Ll Out of Service Well t7 PUMP INSTALLATION 0 SYSTEM REPAIR U tW"'µ'4LOTHER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK At? SEWER LINES 25 DISPOSAL FLO._ M PROP. LiNE _k3 r FOUNDATION �5 r AGRICULTURE WEL N l+" OTHER WELL 2-1 'r PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST F UCTION SPECIFICATIONS �r 1I industrial C3 Open Bottom O Manteca Dia. of Veil Excavation____f Ur" Dia. of Well CasingFI Domestic/Private *Gravel Pack 0 Tracy Type ofasin ` ' g-��-� �Y� 5pedlicatinns FI Public [11 Other n Delta Depth ol Grout Seal F� ` _ _� Type of Grout I I Irrigation 5�Approx, Depth 11 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ 0 Well Destruction 0 Well Diameter ley/ Sealing Material & Depth Depth Filler Material. R Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) n Installation will serve: Residence__-_ Commercial____ Other lC` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth \ SEPTIC TANK © Type/Mig Capacity No. Compartments PKG. TREATMENT PLT. L1 Method of Disposal Distance to nearest: Well Found tion Property Line LEACHING LINE L"1 No. 8 Length of lines Total length/size _ FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will bedone 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: "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." Theapplicant ust call for all to uir d Inspections. Complete drawing on reverse side, Signed X Title: 1` Date: - j --f( >?f ce- t 'c 4 ZS Ztr) if fnrGc IA' FOR DEPARTMEN USE ONLY (! Application Accepted by Dat � Area Pit orrout Inspection by Date Final Inspection by � ' CLL Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Realtt. Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. EH 1321 tREV,iimm