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Y ' APPLICATION FOR PERMIT SAN'_J0AQU_LVmC0UNTY PUBLIC HEALTH UERVICES NMENTAL HEAbTH DIVISION HAZELTON AVE. , PHONE (209)46$-3420 0 BOX 2009, STOC TON, CA 95201 D EXPIRES 1 YEAR FROM DATE 15SUED (Complete in Triplicate) Applica ereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in cmwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. "� 1 Q 1 t (+�11� City ( Lot Site/Acreage Job Address .�}� {o �'j Owner's Name 114TO 1r (, Address o �� /�� Phone ib Uex '724, Contractor t Ilk LAA Address IA 64-957aW9 License No. 3"Ao3 Phone_ 9h5-�r3aS TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT r DESTRUCTION W Out of Service Well ❑ PUMP INSTALLATION n❑ SYSTEM REPAIR ❑ OTHER I7 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NIT SEWER LINES +/ ' DISPOSAL FLD. &9-- PROP. LINE _L...._ FOUNDATION S� AGRICULTURE WELL MY- OTHER WELL__�` PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n , , .� r .�, �.Z L� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_:_ .1r Dia. of Well Casing fa Domestic/Private A Gravel Pack 17 Tracy Type of C sing�W `>qpyG Specifications t I'l Public EI Other n Delta Depth of rout Seal ^ Ars-� Type of Grout l�f'/"f ", I 1 Irrigation -_Approx. Depth I 1 Eastern Surface Seal Installed by 6a)le'1l Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter -(pz�Jr Sealing Material & Depth /� roEd lrrAi lu is l Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I OESTRUCTION I I (No septic system permitted it public sewer is available within 200 feetA 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. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size — FILTER BED Cl 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 1 have prepared this application and that the work will be doie in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Borne owner or licensed agent's signature certifies the following: "I certify that in the performance of ilia work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensa lion 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 compensa- tion laws of California." The applies t must call for all required t spections. Complete drawing on reverse side. Signed - Title: �O Date: vet..yr? I!t a.S art `Jorl af rFOR DEPARTMENT USE ONLY 1e. [�-r Application Accepted by Date Q Area Ll .3 Pit or Grout Inspection by Date Fifial Inspection by Data Additional Comments: Carl " 5 f Applicant - Return all copies o: San Joaquin County Public Heal 1h Services, Environmental Health Permit/Services 1601 E. Hazelton Ave.. P 0 Box 2009. Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH -cm 1/-2e(REV..tin51 INFO `1W �� L1/� EH