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APPLICATION FOR PEMIT ._._,.v �.� I� SAN JOAQUIN COUNTY PUBLIC HEALTH,SERVICES 4 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 Z4 P 0 BOX 2009, STOCKTON, Cg 95201 SCANNED PERMITFROM DATE -IS51Z]M '. (Complete in Triplicate) ` Agplication is hereby made to Sin Joaquin County for a permit to construct and/or install the work herein described. This it �;:applicetioo is stade In carlliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Sealth Services. ` V f 4 TH STR C<-7- Job Address Lot Size/AcreageIcitySA I .,' Y OwnertName GIT 17F�TRA-Caddress �ZD -R#C ELVD, 44C PhoneZO 36#42o _ G. �r;� 140( OAL)lAAb Drt, #l�}a (C'9•' Ctintractor�fROVnI h Ih OCQ£, Address w�Sr Sh�Rr1M rr a license No,15-IgZi � Phone« ?Z,4-16. TYPE OF WELL/PUMP: NEW WELL ❑ WELF REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FO.UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Eircavation 5 le4co Du. of Well Casing Z 1r4c C7 Domestic/Private 5KGrovel Pack ❑ Tracy Type of Casing PVC /r Specifications S C#�P. 40 Il Public n Other Il Delta Depth of Grout Seal Type of Grou 1-44 F.l I 1 irrigation ._ _�I Approx. Depth A I Eastern S rface Saul Installed by SOILS 6-X I-04L4-7-10-,r 54-le WCC-.5 p Repair Work Done 0 Type of Pu H.P. ^� -- -- State Work Done_ A Well Destruction ❑ Well Diameter . 2-tnlC# Sealing Material i Depth CIOtl 1-Y'., „rrd.✓ �_ Depth Filler Material k Depth J_? -5,1Nb -V --4'—.2 AV _-- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i _ installation will serve: Rasidenoe� Commercial_ Other Number of living units: I Number of bedrooms ' .Character of SOA to a depth of 3 foot: Water table depth SEPTIC TANK. ❑ Type/M}g Capacity No. Compartments �- PKG. TREATMENT PLT.❑ Method of Disposal 7 I(Q41ance to nearest: Wali Foundation Pr I� operty Line LEACHING LINE ❑ Np. 111ength of lines � Tote) length/size FILTER BEDp ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITSI P I ! Dapih Size Number SUMPSILl Distance to naarslist Well Foundations Property Line DISPOSAL PONDS ❑ I hereby certify that t have Prep Trod`this application and that the work.will be.done in act:ordence'with San count Joaquin ordinances, state laws, and 1 rules and raqulations of the SanJoaquin County R y Home owner or licartsed agent a kigmture certifies the following:''I certify that in the perfofmance 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 campent 006 laws of California."Contractor's hiring or subcontracting signature I tasrtifias the foiowwtg:"I Certify 'thrat in the performance of the work,for-;which this�pormit is issued, I s tion laws of Chall employ persons subject to workman's corrspensa• j alilomla.• Thf applicant must CaN for alrr !'Ulred Ih n' rr'r rt. /tea req spectiont Complete dra'wrng on reverse side.. + T1. .�SS9elfl 7� Ci-2, 1'ti�C T Date- _/Z-Z3 9 i FOR`DEPARTMENT USE ONLY' Application ACCepted byData �� i Area a ` f * ' Pit 'Grout I � .�- • nspection by Date Final Inspection by Data Additional Comments: y Applicant - Return all'! cop ; to: San Joaquin County Public tleeath Services �k EDviroemental Health permit/Services ,- � •" 11 /// �� 445 N San Joaquin, P O Box 2009, Stkn, IIA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY :NFO DATE PERMIT NO. FiE �1 LZ. '6 Z7 /r! I %� ClEM SY74 IREV.t r rr slI;fMi�•}1 i �h.