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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YkAR FROM DATE S Q/9-S/Tc- (Complete in Triplicate) 0gRc Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in cowliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address s0 . S/AlCLAlQ aVF-' (Rd City 154444 Aa--- Lot Size/Acreage MAf-LEY coat-/A/4 .wq) Owner's Name EAL c.QA4'y,-NY Address IT?,- A(' SINGGAt�. 4ViE• Phone �l CA g P.O.p.o. sox g'a53'V -af37 0-S� Cho } Contractor 0141- WAr69 'WEU D'�U ddress . 6��' �� License No.. T01337 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CIOTHER ❑ 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 SPECIFICATI NS - PLi+:�4S� 5�� FCiU �y Ix Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %a 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ SM EL Specifications I'1 Public xother AMtTM n Delta Depth of Grout Seal / _- --_ Type of Grout t� t I Irrigation T Approx. Depth I 1 Eastern ''//Surface Seal Installed by_ Aiflftl- Wfj1FK c��i'L Repair Work Done U Type of Pump,S90�l6t-f H.P. !2- State Work Done Well Destruction O Well Diameter Sealing Material.& Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION I 1 DESTRUCTION I I lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other -Number of living units•. Number of bedrooms Character of sell 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 ❑ No. 6 Length of lines Total length/size FILTER BED Q Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 workmen's compensation laws of California."Contractor's hiring or sub-contracting signatufs 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 compenes- tion laws of California.,, The applicant must call f ed inspections. Complete drawing on reverse side. Signed rine: TZ tl-O�iIS'r Date: S DC1 �3j /AX FOR DEPARTMENT USE ONLY Application Accepted by - ,� a+�""'-'i - Dats � � •� Area Pit or Grout Inspection by Date &An Final Inspection by ✓ Date M r 3 Additional Comments: -- M�J �7 r �� 11110-0- JA)i4- l bC�r/F(EP] Applicant - Return all copies to: San Joaquin County Public Health Services ee Environmental Health Permit/Services 445 N San Joaquin, P 0 Bax 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK J INFO CASH RECEIVER sY DATE PERMIT NO. • EM 13-21[REV. i w sl ag Est 11.2e r�