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ti APPLICATION FOR PERMIT l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES it ENVIRONMENTAL HEALTH DIVISION i 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT_EXPIRES_-1 -)LEAR FROM 'DATE ISSUED (Complete in Triplicate) Application is hereby made,to taw Joaquin County for a permit to construct and/or install the work herein described. "This application is made in cemliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 16 Q 3 U Al. Ca a a y CityC Z`fsxa Lot Size/Acreage () Owner's Name 119 n n i A Our, A n h n i r k Address 7 5 9 6 C�O r s a a - A p f 4( ,1; Phone r Contractor C.e¢itk Praii, Inc,Address2024 E. Chazti-alt Lr License N0.3 7 15 6 0 Phone 462-7-6"76 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service_Well -❑ PUMP INSTALLATION,4a, SYSTEM REPAIR p OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK ,��5�1 �- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E) Industrial _❑ Open Bottom _ p Manteca Dia. of Well Excavation nom_ - Dia. of Well Casing .-f.1CPomestic/Private x®,Glravel Pack 0 Tracy Type of Casing_ Specificationsil I'1 Public El Other f Delta Depth of Grout Seal ;F I Type of Grou I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by rV I Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Filler Material i Depth --. ti j� TYPE OF SEPTIC-WORK.•,i,NEW INSTALLATIO _I_.l REPAIR/ADDETION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installationwill carve: Residence_ Commercial_ Other Number of living units: Number of bedrooms F Character of soli to a depth of 3 feet: Water table depth If SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. E Length of lines Total length/size FILTER BED- 0 Distance to nearest: Well Foundation Property Line v SEEPAGE PITS 11 Depth Size Number 4 SUMPS CI Distance to nearest: Well Foundation_. - __ Property Line DISPOSAL PONDS C3I 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 ragulatione.of the San Joaquin county *: `� Home owner or licensed agent's signature certifies the to-llowing: "I certify that in the performance of the work for which this permit is issued, 1 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 Califon The sppliean call r r r n ns omp)ete,drawing on reverse side. SignedTitle: i17Q . a� 1.1 e.�* I E. Date-3- DP c 92 _ f OR DEPARTMENT USE ONLY Application Accepted by LkA 106 . Date '— Area 2- Ph Pit or out Inspection by,t J ate inal Inspection by 1_n:�--J Wil//tel / Data 6- Additional Comments: 'Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin Box 2009, Stkn, CA 95201 1 FEE AMOUNT DUE AMOUNT REMtTTE CK RECEIVED BY TE PERMIT'NO. } INFO . EH 14- tRFY.riKs1 EH 13-at r V 1 eg