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APPLICATION` FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 �►C `E°' (Complete in Triplicate) Application is hereby toads to.San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ocupliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. II I Job Address Pco City W.GY•t'?r —Lot Size/Acreage^-,;L1 ip X 1.-'ri(oK P t27r Owner's Name SID y0As' LUCL CQ_ ,____ Address leo. PDX 2115 ffi�h g -- Phone i Contractor4 1&W !�L= Address Y' License No. 112 Phone TYPE Of WELL/PUMP: NEW WELL C] WELL REPtACEMENT n DESTRUCTIONAk Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,❑ Monitoring We31S X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ QW USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' :Domestic/Private. ❑ Gravel Pack7 ❑ Tracy Type of Casing -_�nL�l Specif ication-SC 1eA 40 4 10 I'1 Public Cl Other "I n Dena Depth of Grout Seat Type of Grout — I i Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. Stale Work Done Wall Destruction O Well Diameter ( Sealing Material i Depth Filler Material i Depth Depth,2()� "� TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted it public sower is Available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedroo s Character of soll to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ �; Method of Disposal Distance ito nearest: Well Foundation Property Line PAYM i,+► 4� ° LEACHING LINE ❑ No. & Length of lines Total length/site FILTER SED ❑ Distance'to nearest: Well Foundation Property Line� �j '� Z} �9qs SEEPAGE PITS It Depth t sire r A Number SA5d SUMPS L1 Distance ito nearest: 4K Foundation Property Lina �L3a�1 Ts iQ � y$lQ� DISPOSAL PONDS ❑ .! i�i ENVIRO�M I hereby certify that I have prepared this application and that the work will bedone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquih County I - t 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 I certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion lam of California." i The applicant must call for all required inspections. Complete drawing reverse side. Signed X— -L /' title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date �� Final Inspection by 5, Date o Additional Comments: u� m _o� a n P Applicant - Return all copies to: San Joaquin County Public Health Services (J Environmental Health Permit/Services Joaquin, 445 N Sea Joaquin, P O Box 2009, Stka, CA 95201 � FEE AMOUNT DUE.1 AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO CASH . EM 13-24t41tV.�iRsi �L/v✓ IJV" 1 D�c� �U i3 �� - i •�fH 14•28 ' I