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APPLICATION FOR PERMIT � CA SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRTsS 1 YEAL DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for a-perrait to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address R Z�to71 /�� G�4l� S _ _ __ _ City Lot Size/Acreage 00 Va. Owner's Name '+tChr� _ _ Address 7 SO LJ 14eS P Phone 3312 Contractor<f,�"'_Greco. Address 2t.g2s,4 74 License No. Phone aX,210 TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT C❑ DESTRUCTION ❑ Out of Service Well 0 i PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C3Monitoring 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 M Industrial 0 Ogen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing a U Domestic/Private 0 Gravel Pack C] Tracy Type of Casing Specifications ❑ Public Cl Other 0 Delta Depth of Grout Seal Type of Grout EJ Irrigalion Approx. Depth ❑ Eastern Surface Seal Installed by a )l Repair Work Done U Type of Pump H.P. State Work,Done _ Material Z ' Well Destruction D Well Diameter Sea...,� Depth � t ,.-Ry Depth Filler Material i Depth'+ TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADDITION 0 DESTRUCTION M (No septic system~permitted if public sewer is f available within 200 feet.) Installation will serve: Residence_Y_ Commercial— Other Number of living units: Number of bedrooms_. 4 _ -� } Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. lef Type/Mfg 1 L �; � • I Capacity—plod- -- No. Compartments PKG. TREATMENT PLT. 0 �• r r Method of Disposal Distance to nearest: Well /70 _ Foundation Property Line 4S LEACHING LINE ❑ No. & Length of lines", it�* (ao elg ___ Total length/size FILTER BED rl Distance to nearest: Weil Foundation ?,5— Property Line SEEPAGE PITS 11 Depth Z Sirs Z r� f !A Number_ A: 3 X11 SUMPS L1 Distance to nearest: Well [')0' Foundation 2 Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquir)county ordinances, state laws, and r rules and regulations of the San Joaquin County ' 1 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tl o The applicant must c or all ired inspections, Complete drawing on reverse side. Signed Title: C r.S Er Date: 1-f 0 FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area ��2 a or Grout Inspection by �: '�9�—�— Date u-2 1 1U Final Inspection by `� a Data Additional Comments: CA— . t^S 2 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CASH CH ED BY DATE PERM17'240. INFO ��tt .�f H �f /� . Em 13.24 IREV.i N 01 I��c[ /`� V V ��j �� r// �" V 14% EKA-211