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SAN Jt APPLICATION UIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 20090 STOCKTONO CA 95201 PERMIT EXPIRES I XEM FROM DATE ISSUED (Complete inTriplicate) 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. IMS AAA-. Harnev 1_anP_ 5,ani tary landfill r:,., I ntii Lnt Size/Aera"e l i i arrbc 1810 E. Hazelton Ave. Owner's Name aunty Address tQn CA 952,Dl Phone f,�Q Emcon Associates/ 6330 S. Brewer Rd. Contractor A] l Terrain Dri l l i na Addresspleasant GrDve : CA: CA 95568ticense No. -43783 phonE96-771-0222 TYPE - - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR Cl ,,� OTHER O Initorl Well DISTANCE TO NEAREST: SEPTIC TANK N�.SEWER LINES 1 -MO DISE S�1W� eeoo PR P LEa FOUNDATION 'S• AGRICULTURE WELL OTHER WELD Pi/ LIMPS .sem INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial O Open Bottom O Manteca Dia. of Well Excavation - Dia. of Well Casing 112et Ci Domestic/ Private XGravel Pack7 D Tracy Type of Casing_ PVC SCiE� 40 Specifications t 11 Public la Other fi Delta Depth of Grout Seal t total Type of GroutbenSeal i I �Irtqflatlyo 30-55.. Approx. Depth I I Eastern Surface Seal Installed by Re158,r Work L3 U Type of Pump M.P. State Work Done _ Well D ructi O W I Diameter Sealing Material & Depth i We°�'ls{vapt th FillerMaterial & Depth E OFSEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installatior �uni Residence _ Commercial _ Other Number of liviNumber of bedrooms Character of septh of We depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well oun Property Line LEACHING LINE Cl No. & Length of lines ength/size FILTER BED Cl Distance to Well Foundation 2Property Line SEEPAGE PITS I Depth Sire Numbe SUMPS Ll Distance to nearest: Well Foundation SAL PONDS Cl I 1:01evy eoru,y mai , nave prepared erns appncauon dna tnat the work will De done 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 workmen'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 applicant m st call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: --/,� e FOR DEPARTMENT USE ONLY Application Accepted by Date 10 k-1 it Cl Area 1Z t i I_ Pit or Grout Inspection by Date Final Inspection by �_ Date 1, ©f"I''9 1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 - - - _. - _._ - k, I s FEE IpNFO AMOUNT DUE 1 AMOUNT REMITTED I CASH RECEIVED BY 'DATE PERMIT'NO. . EH 1324(PEv.,iwSl'Y& EH 1/-2a ,-K , �®® •b® 1i 1C)—L%- -! - .7 l i� - - - _. - _._ - k, I s