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APPLICATION FOR PERMIT { U r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PTRMIT EXPIRES 1 YEAR FRQM_DATE ISSUED (Complete in 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. It Job Address 1 U 2 &O (92e fS /--ga K e City A 19d ) Lot Size/Acreage,-9.0 az-&—e-S / .hood ism) g e Owner's Name tQt-S(G y a_&eD S e_ Address QQ "r1.tL� P'l ti Jeltg t�u nr _ Phone - Contractor V&&-st D All1i Address Q-AQ x yQ 6,d /r—License No.e'Pq Z$l Phone_ 'a TYPE OF WELL/PUMP: NEW WELL,;59 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 11LL SEWER LINES /-SD DISPOSAL FLD. PROP. LINE 12" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Cl Industrial XOpen Bottom ❑ Manteca Dia. of Well Excav tion Dia. of Well Casing Cl Domestic/Pfivate ❑ Gravel Pack ❑ Tracy Type of Casing e_ Specifications I'1 Public 1-1 Other f 1 Delta Depth of Grout Seal Ty sof XIrfigation q;��Approx. Depth I I Eastern Surface Seal Installed by ua �IrJ_�7_f2a jA� Repair Work Done U Type of Pump SvH.P. IS _ _ State Work Done — Well Destruction ❑ Well Diameter Sealing Material 8 Depth C Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 taws 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 must call for all required inspeetions. Complete drawing on reverse side. SigneJ��&I ,*AA A �h 09--- Title: , Date: FOR DEPARTMENT USE ONLY ApplDGouCt epted by G Date U Area c Pit Paction Data ^ [ [ final Inspection byAddrment,: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA N RECEIVED BY DATE PERMIT'N0. . EH'A-2,IREV.r,H 5) �r EH 71.2E