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APPLICATION FOR PERMIT �� ( J I SAN JOAQUIN COUNTY PUBLIC HEALTH SFFRVICES � t{ ENVIRONIMTAL HEALTH DIVISION 445 N SAW.JOAQUIN, PHONE (209)468-3420 P 0 BO% 2009,' STOCKTON, CA 95201 � PERMIT MIRES I YEAR FROM DATE ISSPBP (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. Job Address _�� l nl/nnJ .�� City S f "ck*024 Lot Size/Acreage g sft7AJ Owner's Name (4 A)1�4rJ L C.F C[) Address _-/Sat) CA). WEd.&:-0 Phone '` 2 7 P4 B0?- L153/ Contractor d h! 7) 1'tf LL/14Address-&-AP-9111 CLL3L 5'2 License No.C-S2/4/7 phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �"-''=f`''---_ SEWER LINES --2S7-' __ __ DISPOSAL FLD_AY_4 PROP. LINE �[ FOUNDATION AGRICULTURE WELL OTHER WELL `�A / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 1/L Specifications VI Public -1�Other V Delta Depth of Grout Seal Type of Grout I I Irripalion —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter r� Sealing Material i Depth 5L- aA-2FAs5 - th �y r Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION f 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 3 1 Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments lLLJ11 111 PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS v Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin Caunty Home owner or 4onsed 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 per n in such ma or as to becorna subject to workman's compensation tows of California." Contractor's hiring or sub contracting signature certifies the fo wing: "t certi f hat in t performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Ifanla." The appfica st II for I requi ins ions. Complete drawingZ arse side Signed Title: GC-+ 9 C _ Date: `r�1 53 FOR DEPARTMENT USE ONLY ST Application Accepted by Date I Area �✓ Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT N0, EN tide IN 13-24 JREV.ii11s1 wM S9. oo q3 n4 l