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APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95203. (209) 468-3447 R (Complete in Triplicate) Application is hereby madelto San Joaquin County for a permit to construct and/or install the work herein described. This application is made in co4liance With San Joaquin County ordinance-No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. Job Address x7,96- f);n kr-5_';a City Lot Size/Acreage 4 O�putt6r i Name Y��Address �uV - Phone Contractor MSS X4J*A Address-3_5_3 •L me-61'J 42_( License No. �3��Phone S 240y� �J TYPE OF WELL/PUMP: y . NEW WELLWELL REPLACEMENT ID DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION f.7' SYSTEM REPAIR © OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP, LINE s �j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4.'!ur INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_'1 Ind trial pen Bottom ❑ Manteca Ois. of Well Excavation Did. of Well Casing' omestic/Private ❑ Gravel Pack I7 Tracy Type of Casing Specifications. - M Public (1 Other ❑ Delta Depth of Grout Seal ype of Grout - --- IJ Irrigaiion ._.,,.Approx, Depth Cl Eastern Surface Seal Installed by 11 Repair Work Done 0. Type of Pump a4k.1 H,P. 5 State Work Done _. Well Destruction ❑ Waal Diameter L Sealing Material & Depth *� Depth Filler Material 4 Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.1 Installation will.serve: Residence_ Commercial— Other ° Number of living units: ,. Number of bedrooms ¢f, Character of soil to a depth of 3 feat: i i Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. Cl - E Method of Disposal 4 F Distance to nears t: Well Foundation Property Line -*-r LEACHING LINE ❑ No`&''Length of,lines f Total length/size FILTER BED n Distance to nearest: Well " �"` " -Foundation Property Line SEEPAGE PITS t I Depth Size Number SUMPS Ll Distance to nearest: ` Well _ "- ` Foundation Property Line a DISPOSAL PONDS O t} I hereby certify that t 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 1�ii, 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,:F employ any person in such.manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signal` canities the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compo" tion laws of California." ° The applicant m st call r aN r d inspections, Complete drawing on reverse side, _ac 4A Signod Title: �w �'- 6 Dote: ' r i } DEPARTMENT USE ONLY q �a ` t Application Accepted by ��"�� Date `_ l L Area 0 Z1 L�f Pit or r0 Inspection by ,2, Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY AUBLIC HEALTH i3ERVICE9 - ENVIRONAlENTAL HEALTH DIVISION PEFtWIT/SERVICES 445 N SAN JOAQUIN, P 0 BOR 2008, STUCKTON, CA 85201 t 3 5 FEE iNfO/f AMOUNT DUE AMOUNT REMITTED CASH AkEIVED BY DATE PERMIT NO. • EH 13.24 1REV.I/M str�yf �`3� m� `f?� 2. 04 09 i EH w2e � � (_-2