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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 o P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR_FRQM DATE ISSUED DD (Complete in Triplicate) L „ , moi Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application fs made is compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of San Joaquin County Public Health Services. Job Address aSo2-,._' :* 4019d City S A _ Lot Size/Acreage Owner's Name &dgaL 4E3mg-'s/S Address 5-1m6 Phone Contractor 1 E.dYU L0,P01n, _' -Address TAA AbdSA=dA AAT A4/57 License No._J&fP_7L Phone " 1911 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications t1 Public Cl Other Cl Delta Depth of Grout Seat Type of Grout - I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by VA Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller liaterial i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADOPTION i I DESTRUCTION (No septic system permitted if public sewer is / vailable within 200 feet.) „ /t Installation will serve: Residence w Commercial_ Other Number of living units: Number of bedrooms f Character of&ON to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Wail 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 subcontracting 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 must call for all_requuiireedinspections. Complete drawing on reverse side. Signed X Czaa Title: - &1;47 _....., Oates FOR/1 DEPARTMENT USE ONLY c �_ Application Accepted by y, �• ��10...�!'�, Date '" a�� Area 0 7- 1 Pit or Grout Inspection by DateFinal Inspection by Date /' Z b z_ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin P 0 Box 2009, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED K RECEtvED BY ATE PERMIT'NO. r EN 13•74{t1EV.1/x61 �(� 7'/.Oct . oa 4G0 7 fH 14•Ze �/