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I' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH S19RVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE, ; PHONE (209)46$-3420 P 0 BOX 2009, STOCgTON, CA 95201 -' = 1Lit REMIT EXPIRES 1-YEAR IT�ROId DATE IS$ T (Complete in Triplicate) J �lnt` Application is hereby made to San Joaquin County for a permit to caftstruct and/or install the vork'her in described.-'-This application is rade in acepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. - = ;_`._ Joh Address f)/ Svr.TEF �c rHLA City S i Lot Siie/Acreage 4"11- Owner's Name 0144,T4t. heW,4e4 e., Lle&XT Address -UO a- ! ff+leu-3 t 41444010 Phone- 4157- 143 ' 05 Contractor Saeor% fnXPwEAzrg'1-_Address i'SK �• Q'er} $T Sr"uc-rv^i License No. Sl -L'P Phone .�°.4 f• P TYPE OF WELL/PUMP:` NEW WELL CS WELL REPLACEMEN_T ❑ DESTRUCTION ❑ Out of Service Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR p OTHER ❑ monitoring Walt" DISTANCE TO NEAREST: SEPTIC TANK IVA..- -- SEWER LINES �+ DISPOSAL FLD. .AIA PROP: LINE - FOUNDATION LSr AGRICULTURE WELL OTHER WELL I Sy ' PITS/SUMPS /VA i _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12- Dia. of Wed Casing — I:d Dom Nc/Private 0 Gravel Pack ❑ Tracy Type of Casing �C' Specifications avc4 1'1 Pt blic r a�,n7 _.Fl other rren,rne,n j CAI Delta Depth of Giout Seal 0`�r Type of Grou N-47 7 f I I Irrigation 3o'.Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump NR H.P. State Work Done Well Destruction ❑ Well Diameter 'f n Sealing Material L Depth 1?e.1- on;f Depth 3a r. Filler Material i� Depth' -0 2fi z Si},td a2 c4.t7 V*1 ±1- TYPE OF SEPTIC WORK: NEW INSTALLATJON 1 I REPAIR/ADDITION I I DESTRUCTION I l INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence:___: Commercial_. Other Number of living units: Number of bedrooms r� Character of soil to's depth of 3 feet: I Water table depth ! SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT.❑ MethiPAYM l T C Distance to nearest: Well Foundation Property Li LEACHING LINE 0 No. 8 Length of lines � Total length/size A FILTER $ED _ ❑ .Distance to nearest: Wall Foundation Propertle�g�,tyjplLp:;NTY L _ I RI If' HFAI,_T1i-1'yERI{lvB---_._.-�._..__ SEEPAGE PITS .- I I_.Depth Size I Number ENVIRONMEINTAL HFAL1li L)WbIUN PASUMPS l LI Distance to nearest: Wei! Foundation Property Line � DISPOSAL PONDS ❑ - __f - __.:_• __ s 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 I rules end 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, f shatl not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or suacontracting signature canifies the following:"I certify that in the performance of the work for which this.permit is issued,1_shall employ persona subject to workman's compenss- tion laws of California." The applicant must callforfor all required inspections. Complete drawing an reverse side. -- - - - Signed �c�r��-�"" Title: _!!re i I �dla9� Dater FOR DEPARTMENT I SE ONLY Application Accepted by Date `1 R Z Area urt Pit or Grout Inspection by + Date.�� Final Inspection by Additional Comments: 4 2• brooi 8r� • - Applicant - Return aU. copies to: Gan Joaquin County Public Health . Services, Environmental Health Iiiermit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 fi - FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY BATE PERMIT'NO. C�A.tFSHra+� ' o EH13.24 iAEv.I.,as? S�. 4! ��.C_Jl� 1 ✓ / r) / ✓ '�` y� ��r wry . EM 14.20 [l