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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY'PUBLIC HEALTH SERVICES PAYme1qr ENVIRONMENTAL HEALTH DIVISION P-04iBOX 2009 , 8TOCKTON' CA 95201 RECEIVED . _ - (209) 468-3447'� OCT z 9 ? $ ,. R . , � SAN JOAQUIN CC�iv Complete is Triplicate} PUBLIC HEALTH SER- , t S d` . .ENVIRONMENTAL 4app atiop Is hereby nada toSaaJon uin Count for n A!-7H i! eatioa Se made in c q y permit to construct and/or install the work herein described. i Health nce,with San Joaquin County Ordinance Ha. 54 and 1862 and the Rules and Regulations San Josgvin County Public Health Services. „V A ?Mz�roN elF APN 74-07o-OC 6,&d-r o r vtvsOE,p) Job Address • —Ue ST efr 7E,-0-70-0'7 City 5,- --r�� Lot Size/Acreage 4-- �g Owner's Name L�q� vw E>r 1, :5e tt3t7 L.dDe 5 i S ihJ, T (rip phone �3 f 72 q Conitactor 5��.-r u1 ` sAddress ?�SZS�: My�-Tt-ES j $fix incense No. ,/� r License No.��phone 4 � S7f TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ,[1 PUMP INSTALLATION ❑ =_SYSTEM REPAIR O I gonit6iing-Well DISTANCE TO NEAAEST; SEPTIC TAMC O r (� / OTHER �,�GuW1CAi [] —1,F� . SEWER LINES '�` DISPOSAL FLD.`II�SQ P P. LINE.-J�-.r gcie_4p ; FOUNOATION _.}ILEW AGRICULTURE WELL• OTHER WELL' _ UDS PITS/$UMPS•?dA 7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ 0 Industrial ❑ Open Bottom' ❑ Manteca Die. of Well Excavation fV 4•F. . Dia. of Well Casing !JA I - r:. g U Domestic/Private Gl Gravel Pack- n Tracy Type of Casing A. : Specifications A Q PtrbliC i'1 Other C3Delta Depth of Grout Seal A Type of Grout af�s [T M Irrigation A + pprox. Depth ❑ Eastern Surface Senl lnstalied by PE LLF,tT C Repair Work Done C] Type of Pump H.P. State Work pone Well Destruction ❑ Well Diameter! Str.sL Sealing Material i .Depth Depth Filler Materis.l i Depth TYPE OF SEPTIC WORK: NEW IN TALLATION l❑ .REPAIR/ADDITION 0 DESTRUCTION LJ (No septic system permitted if public sewer is 1� available within 200 feet.) Installation will server Residency Commercial Other r (� Number of living units; Number of bedrooms �J J Character of soil to a depth of 3 feat: !Water table depth O Type/Mf SEPTIC TANK J � g° Cspatity.,� _ - No. Compartments O PKG. TREATMENT PLT.0 Method of Disposal Distance io!nearest: Well ',Foundation Fropeny Line . . LEACHING LINE 0 No. b Lengtth of lineaTl otal length 7sie FILTER BED n Distance to;nearest: Well Foundation iProperty Line - �f SEEPAGE PITS 11 Depth Site Number SUMPS LI Distance toinsarest: Well Foundation + DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and-that the worts will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin Cour.,y Home owner or licensed agent's signature cenifies the tollowin "1 semi! that in the em Io an g Y performance of the work for which this permit is issued, I shall not p Y Y Pelson an such manner a5 to become subject to workman's compensation lawi 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 issued, I sha tion laws of California.", persons employ pens subject to workmen's compensa• A The applicant mu It.for a quit insXor Comp; a Ing on reverse side. Signed1146 11.1 E7� �tle• }' Aata: y x FQIR DE RTMENT USE ONLY i Application Accepted by r^+'�fC/ te �� - '� Area Pit or Grout Ins I I}action by Date Final Inspect408b Date Additional Commems: �t.r 4 .. w (�p ,cgpieto: sS JOAQL'INC01J1iTY PIlBLIG HHALTK SERVS ` " ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES R.1 445 H SAN JOAQUIN, P Q 008, 5T()CKTON, CA 65201 FEE AMOUNT DUE As,+lOUNT_fleminED CrC HJ. INFO RECEIVED BY DATE PERMIT'ND, x EM 144 ACV. /�