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"y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 20090 STOCKTON, CA 95201 (209) 468-3447 PERMIT ESPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby Awde;to San Joaquin County%for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules.aad Regulations of San Joaquin County Public Health Services. Job Address -� J �'� SCitySfae,Ei Lot Size/Acreage ///101 13 161' Owner's Name�aC/' C Address = saw --70k- !%/J.d Phone' 1/ es/Q?,!,fC �/ /O Contractor CGrr d�Gt�v+� Address_ 'q -Yi'�+��,,,,•��, U CSV License No./3751�-�- phone a �`�/a0 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REVAIR 0 OTHER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 7100�^ . DISPOSAL FLD, /102> PROP. LINE A-117 FOUNDATION '7aO AGRICULTURE WELL? /Oa / OTHER WELL?/aO / PITS/SUMPS;7—eed / INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation 144- Dia. of Well Casing xml U Domestic/Private C'l Gravel Pack ❑ Tracy Type of Casing Specifications — - 0 Public Other GnhnoJ ❑ Delta Depth of Grout Seal _ 6*0 /�, _. Type o! Grout CJ Irrivation t�'.Approx. Depth ❑ Eastern Surface Seal Installed b ~e Repair Work Done Ll Type of Pump NX H.P. _, ,yi4 State Work pone, Well Destruction ❑ Well Diameter —�— Sealing Material i Depth f C>! ere -fjy (o O Al/4 Depth_ .�' IGy driller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITiON M DESTRUCTION CJ (No septic system permitted if public sewer is available within 100 feet.) Installation will serve: Residence, Commercial Other Number of living units: Number of bedrooms Character of *ON to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments y —� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Q No. b Length of lines Total length/size FILTER BED C•1 ,Distance to nearest: Well Foundation Property Line (� SEEPAGE PITS i I Depth Size Number SUMPS LI Dii[anee to neeresl: WON Foundation Property Line (r DISPOSAL PONDS ❑ I hereby comity 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 agenes'signature certifies the following: "I camify that in the performance of the work for which this permit i issued, I shall matem to any person in such manner as to become subject to workman's's compensation laws of California." Contractor's C hiring or sub-contracting signature certifies the following; "I certify tfial 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.,, it The applicant must coil for all requiredinpwtions, Complete drawing on reverse side. Signed X /�4 CTG(J� -2-2741-> Tide: Date: 3 l3' FOR DEPARTMENT � ,00 USE ONLY ST Application Accepted byrr o Dots . Area � _ Pit or Grout Inspection by Date �. Ll Final Inspection by O°' Additional Comments: I s, ' Applicant - Return all copies to: SAN JOAQUIN COU6TY PUBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO EK 1-gCASH /�-, ry r7 ��ryy . EH 1�•2�111EV.i�wbi 130 /�/{ ��7f y�� I Y�