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I APPLICATION FOR PERMIT f� i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 r (209) 468-3447 X PERY,IXIRg5 1 YEAR OR-OR-DATE ISSUED it (Complete in Triplicate) H I� Application Sa here made to San Joaquin Count for a 17P by q y 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. II Job Address /p City Lot Size/Acreage 3oSXJ641l- _ Owner's Name 7119AI kiIVALQDX Address 54T14�6 Phone 9 .- I i Contractor FLmi/D E. LtAW Address �z dZ. A&E-E1-.s�.27- •YX License tufo. 41 7" Phone A01'397 TYPE OF WELL/PUMP: r NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl ~ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring well, G7 DISTANCE TO NEAREST: SEPTIC TANK SEWERINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU TURE WE OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA COTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing t. U Domestic/Private ❑ Gravel Pack ❑ Tracy 5 pe of Casing Specifications M Public i'1 Qther ❑ Delta t De th of Grout Seal Type of Grout M hfsoation ,�.Approx, Depth C] Eastern Surfs a Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done_ WellDestruction ❑ Well Diameter Sealing Xsteri�al L Depth Depth `Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION P4EPMRIADDITICIN M DESTRUCTION.M (No septic system permitted if public sewer is / available within 200 feat.) installation will serve: Residence— Commercial Other A[17Z7 fCt/� G�'l�ticr y�7jQd �� l Number of living units: Number of bedrooms SuPPcE .w1� Sysr�,.c Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C Capacity__1 No. Compartments �- PKG. TREATMENT PLT.*Cl Method of Disposal e ,Distance to nearest: Well -I-7X Foundation J® � Property Line LEACHING LINE No. & Length of lines�� Total ` FILTER BED n Distance to nearest: Well-_1 00 f` Foundation - /_Ea ' Property Line SEEPAGE PITS lr Depth 3_.;1 r Size 4 ,S711 Number _ SUMPS LI Distance to nearest: Well Z 4 r Foundation ' Property Line '),eq` 9 DISPOSAL PONDS .,. ❑ It I� I hereby certify that I have prepared this application_and that the work wjll„be.done„in,.accor.dance 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 mannan 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 insPection&. Complete drawing on reverie side. Signed Title: Date: /l: 7 10 FOR DEPARTMENT USE ONLY Application Accepted byDate G Ares Pit or Grout Inipection.by Date Final Inspection bye^ Date C, Additional n r Additional Comments:-' Applicant - Return rill copies to- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201FEE r i. INFO AMOUNT DUE AMOUNT REMITTED CK 0 _TCASHi RECEIVED BY DATE PERMIT NO. I . tK,,.z,tAF,,.„x s,fH 114-20 l t 7 9r zq " I