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` y37 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t 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 Slade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in caepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / q ( ?4C G( � City Lot Size/Acreage (/? c-C. Owner's Name AP U 45 (�/ f JS 7) � ,Address 7q ��Gr Cr Cr, Pi/ 2u� Phone �C Contractor l ,T/w"C�t )'' /_ & // dress f / License No..51`2( 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump — H.P. Stat Work Dons_ Well Destruction Well Diameter Sealing Material i Depth n Depth SS,_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation w81 serve: Residence_ Commercial_ Other ` Number of living units: Number of bedrooms \V� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. CorMEN. PKG. TREATMENT PLT.❑ Method�tl�iscsaa Distance to nearest: Well Foundation Property Lin�1�i+Cr�r�C� LEACHING LINE D No. & Length of lines Total length/siz QA 1141 P1111 luly FILTER BED ❑ Distance to nearest: Well Foundation Profet _ 7,TERVICES ENVIRONMENTAL HEALTH DIVISION SEEPAGE PITS 11 Depth Size Number-- SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus or all r9qu1rpVhqwtions. Complete drawing on rev side. Signed Title: -'t e Date: F DEPA _____ Application Accepted by - Date raa Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 I,F EE 0 AMOUNT UE AMOUNT R ITTED K RE EIVED®Y D TE PERMIT'NO. . EM 13.24111EV.heli) 11 1 � 1 /m, 7 EH 14-M lVV/"""