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f � APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 RECEEVED P 0 BOX 2009, STOC%TON, CA 95201 FEB 0 Z 1943 1 PERMIT EXPIRES T YEAR FROM DATE ISSUED SANJ,10AQWN COUNTY (Complete in Triplicate) VUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 vith Sea Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /l7 6 ,Sf-Ut9k TJ-E 6Fs�' City (,47W126/0 Lot Size/Acreage ? /ice£ S' (�N&'STZ'" Address " S41`4 �/� � ?� � Phone Owner's Name N J0AI!6; Contractor AdG•ess - r"""mac`•' cense No. Phone`Q/6 60 7 TYPE OF WELL/PUMP: NEW WELL 1htLL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well by DISTANCE TO NEAREST: SEPTIC TANK /VA SEWER LINESc-IlUz DISPOSAL FLO. N# PROP. LINE, 57 ' FOUNDATION'_ 14/ AGRICULTURE WELL NP OTHER WELL Np PITS/SUMPS N✓� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom >; Manteca Dia. of Well Excavation 10 Dia. of Well Casing Domestic/Private '9 Gravel Pack ❑Tracy Type of Casing P✓Ci Specifications _.QZ44 ua / G. I'1 Public ❑ Other �: Delta Depth of Grout Seal Type of Grout ft!)ZrLbAd cs Seal Installed b ,y/1 �i'svr , Y I I Irrigation Approx. Depth Eastern Surface S Repair Work Done (J Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth - Depth Filler Material i Depth Q , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public ;;.or is. ,J available within 200 feet.) Installation will serve: Residence_ " Commercial_ O_ther_ Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet- Water table depth SEPTIC TANK" ❑ Type/Mfg " • PAYMENT- No. Compartments PKG. TREATMENT PLT. ❑ RECEIVED Method of Disposal \ Distance to nearest Well Foundation Property Line FEB 62199 LEACHING LINE. ❑ No. &-Length of Imes CAM VlAr11 HNI rnr IR" length/size FILTER BED ❑ Distance to nearest: Well PUBL&WEAI6T SFRVIM Property Line ENVIRONMENTAL HEALTH DIVISION SEEPAGE PITS -----'I I Depth Size Number p,- 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 done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County -" C Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 4 employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature -f certifies the following: "I certify that in the perfomunce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all re ulrad ' pections. Complete drawing onreverse �side. Signed � / Title: .-__ . Date:.. .� --- / FOR DEPARTMENT USE ONLY Application Accepted by ( Date ?` Area Pit or Grout Inspection by _ Date ��Z�3 Final Inspection by .Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Jp00�� Services, Environmental Health Permit/Services, l/( 1601 S. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �• CASH A, . EH 1321(REV.1/n 51 fH J