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y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES_ 1' YEAR„FROM DATE ISSUED (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 Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County P ublic Health Services. A Job Addres� �C �� / City_C?VCk7V J Lot Size/Acreage Owner s Mame - Address nee 911 00, Contractor,,.�!✓ WZ7 A&ZG Address 6,4oe .3 c 0 A&IRicense No...-9-/6 Xp Pho&? y-$<rV TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I&tori Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 6-r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation._- 8 Dia. of Well Casing D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 5pecifications ; ['1 Public 1'1 Other F1 Delta Depth of Grout Seal %d-X5- ^ Type of Grow ✓�G.egrJr` + I i Irrigation —Approx. Depth I I Eastern Surface Seul Installed by Repair Work Done LJ Type of Pump H.P, State Work pone Well Destruction ❑ Well Diameter Sealing'Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 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 Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 7Z_ P. Distance to nearest: Well Foundation Property Line j LEACHING LINE L-1 No. 3 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to newest: Well Foundation Property Lina DISPOSAL PONDS ❑ I 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 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 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 iwued, I shall amptoy persons subject to workman's compensa- tion laws of Califomia." The applicant must call for all required ins tions. Complete drawing on reverse side. Signed • Date: FOR DEPARTMENT USE ONLY Z-�.�� cS� Application Accepted by ��77?. �J/ Date ea DA i Pit or Grout Inspection by Date 114 v Final Inspection by Date 3 Additional Comments: Y_Jti J��_ Y 5,94"_ay V's 131% 45�B1 ar :5 V5611, 5$12 _ Applicant - Return all copies to: San Joaquin-County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FF AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ^j� //�� CASH RECEIVED �/�(M �J[U � . EH14-2�[REV.rins! -1/47 6Z) �q. L�V �T—iF r-"' \ �'`��qZ �Z�LJ i5 EM i430