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ZZ APPLICATION FOR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -04 P O BOX 2009, STOCKTON, CA 915201 Y� '(209) 468- 7J'V-_:1'0 SA Fri?'2 (Complete in 'Triplicate) fly, U c4, V llyc��1 Applicdtion is hereby made to inn Joaquin County for a permit to construct and/at. install the wo��@*� Thie applictrtion ie made,in compliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and �f' San Joaquin County Public Health Services. APN OtS� lfl-oa 11 70Cv� Job Add diiase *@!E F. Fppz i nen Tgne City_Een - Let Size/Acreage 4+.Acre _ I iII Steven Fop�iano & y Owner's'Name HenryF i= TIT_ _ Address6Q97 11 _, q 411_ Phone( — 11137 ,-- — _ �. 1830 Vernon 5t., Ste. 7 rl Contractpr EARTH rEC. LTD. _.,-,._.Address Rogeyi l 1Q. CA 95678_ _- License NoC-574(1A595_Phon� — TYPE OF,WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C-1 DESTRUCTION o out of Service well 0 Test Borinq PUMP INSTALLATION Q SYSTEM REPAIR 0 OTHER X�Mo toy ll [3 DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES None DISPOSAL FLD. _ PROP. L E an !�h FOUNDATION 2 t AGRICULTURE WELL. 100' _;OTHER.WELL N_Pna____PITSISUMPS None— INTENDED one ..INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r- Indusirial 0 Open Bottom © Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications ❑ Public! f1 Other © Delta Depth of Grout SealType of Grout i M Irrioation __.Approx. Depth Cl Eastern Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P, State Work Done _ i Wel! De truction O Well Diameter Sealing Material & Depth Portland Cemnt Grout, total depth \� i ryi Depth Filler Material i Depth O V TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION Cl INo septic system permitted if public sewer is 11 available within 200 feet.) s Instal!I4ion will serve; Residence^ Commarciat— Other Number of living units: Number of bedrooms nli Character of soil to a depth of 3 feet: Water table depth SEPTIC iANIC ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE LI No. & Length of lines Total length/size I, FILTER BED 0 Distance to nearest., Waft Foundation Property Line I df { SEEPAGE PITS 11 Depth Size Number SUMPS f Ll Distance to nearest: Well Foundation Property Line -DISPOSAL PONOS I haroby,[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 Sen 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 Calilornia," 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 eompensa" ' tion lawi'of California." The applicant must call for all required inspections. Complete drawing on reverse side. ��,, Signed I� Title: �Pringi��. Consultant _ _ Date: �_117A71 OR PAFITMENT USE ONLY [� Application Accepted by Date Area I Pit or Grout inspection by Date Final Inspection by ____ Date AdditionpI Comments: — Appliegat - Return all eopiee to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES t 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H DECEIVED BY DATE PERMIT N0. tNf$ ��jj . EH 13-24 1REV.1/K5! EH;e•26 i