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I APPLICATION FOR PERMIT SAN IN COUNTY PUBLIC BEALTH Z VICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN -JOAQUIN,- PHONE (209)468-3420 P 0 BO$ 2009, STOCSTON, CA 95201 PENIT EXPIRESYEAR FROM DATE- ISSUEQ (Complete in Triplicate) Application is hereby ma4o.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. 544 and 1862 and the Rules sad Regulations of San j Joaquin County Public Health Services. Job Address City S'fVC4tosJ Lot Size/Acreage I sfcrN -- Own 's Name W C F Address !3 W. IUFt6�G S�. _ Phone er P O .8 D?- Lel 11 r� Contractor �r i r—Af ah! D /?I L-k.LylAddress ef O License No.t"-SZ 1 d M Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Yell C1 PUMP INSTALLATION ❑ SYSTEM REPAIR C3OTHER C3Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES 2-5 , DISPOSAL FLO, PROP. LINE –(a*' FOUNDATION AGRICULTURE WELL _ OTHER WELL `�$, PITS/SUMPS` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS JW�ndustrw ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wag Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �- Specifications i'1 Public Other Delta Depth of Grout Seal Type of Grout, I I lrrioation ..r Approx. Depth l I Eastern Surface Seal Installed by a Repair Work Done L3 Type of PumpH.P. State Work Done �.�_ _ Well Destruction ❑ Wag Diameter Sealing Material A Depth a 4.- /461hhrW 1MC Depth �� Filler Material A Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAiRlADOITION i I DESTRUCTION t I (No septic system permitted if public sawN is available within 200 feet.) Instatla6on will serve: Aa silence_ Commercial Other I Number of living units: Number of bedrooms �1 Character of soil to a do"of 3 feet: Water table depth SEPTIC TANK ❑ Typal Mfg Capacity-- No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal J Distance to nearest: Wall Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Wall Foundation Property Line C C SEEPAGE PITS l I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line \ DISPOSAL PONDS ❑ j I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and s rules and requiations of the San Joaquin County Morro 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 2astoecome subject to workman's compensation laws of California." Contractors hiring or subcontracting signature conifim the folldwwq:"I performance of the work for which this permit is issued.]shat]employ persons subject to workman's compsnso- tion laws of iforNs." The tt for reions. Complete drawing on r erre side. �..- Signed ■ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b ( � �� A Area OPI ell Y Oat* Pk or Grout Inspectimt by Date 2/b 7 Final Inspection by Date -- Addltionsi Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environment8I Health Permit/Services 44$ N San doaquia, P 0 Sox 2009, Stkn, CA 98201 FEE AMOUNT DUE AMOUNT REMITTED GK s RECEIVED By DATE PERMIT H0. INFO CASH . EN M24IREw.fia$I wM $q, f3D . 12o MLkt S �•Zl. -l1� I EN�Yati