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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-a44-7 3�/.;`D R (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 1e made in cottgrliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health'Services. 521 NORTH CHEROKEE LANE 9524 ii Job Address City J ODI - Lot SizelAcreage �_ NACRES) Owner's Nam¢ PbHA SED JANEEL Address ,� 'N. CHEROKEE LANE A QDT :^ A Phone t FALCON ERGY W_ AND p,ANCHO CORDOVA C_ Contractor S7 HA7MAT Q11 ! TNa Address 3733 FFT7I;FRAI n Rn.� CA Llcense"Tfo. 55497q Phone" j TYPE OF WELL/PUMP: 111; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well L-1PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ TDOTHER � G FtNonii(toring RINGS Well DISTANCE TO NEAREST; SEPTIG[TANK SEWER LINES DISPOSAL FLD, PR6 1TNr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ E INTENDED USE TYPE,QF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I r� n industrial ❑ Openl�Bottom ElManteca Dia. of Well Excavation `i! 'iZ` Dia. of Well Casing `t T» U Domestic/Private r Cl Gravel Pack 0 Tracy Type of Casing k'7.,,, ,- ' -du 446 Specifications M Public �r r' `'`` OtherL C3Delta 0. Depth of Grout Seal `;(?� Type of Grout �' tallT 7�N l CJ Irrigation ,titr t�+�, r App�ax Depth ❑ Eastern Surface Seal Installed by (74Z i�L�C CiUf�k"r6ane:l t Repair Work Done U Type of Oump H1.P. State Work Dan!.,,— Well Destruction ❑ Well Diameter 1t(AJ 1IV Sealing Material i Depth. ;2 i�t.1 i"I -,�_4L Z ` _ + Depth .I� Fiber Material i Depth ^ TYPE OF SEPTIC WORK; NEW INSTALLATION L7 REPAIRIADOITION - DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve; Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK" I3 Type lMfg J Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line .y LEACHING LINE 0 No. 8'"Length of lines Total length/size FILTER BED [3 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I� I hereby certify that I have preparedl�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 canities the fallowing: "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 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 must call for all required inspeuion ' drawing on reverse side. Signed g Title: Date: F R DEPARTMENT USE ONLY Application Accepted by - y� Date -r Area I , ., Pit or Grout Inspection by � Date Final Inspection by Date Additional Comments; I� Applicant - Return all copies;!t0: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT 06EEJ AMOUNT AEMIT'TED L�rCCK 9 RECEIVED BY DATE �7PERMIT NO. . EH -M iAEV.i i w! IU Cl f A z� f A EH;I.Za A