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} { ) APPLICATIOd FOR PEIRMITf�� t V SAN JOAQUIN COUNTY PUBLIC HEALTH 'SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE'S(209)468 3420 P O BOX 2009, STOCKTON, 'CA. 95201 _ EXP RES 1 YEAR FR iD ^ ' (Complete p in Triplieate):E �•;�. � 44. .`µ: -y �. Application is hereby made to San Joaquin County for a permit to construct and/or:Finsta]3°"the^woik-lxeieiq''described. This application is made in coupliance with Sam Joaquin County Ordinance No. 549 and 1862 and thee.gulation's>,of San Joaquin County Public Health Services. Job Address 10,44 SouthAurord City c•tOCktoft Lot Size/Acrea&e 1/2 a'[r0 ,; I 466-2973 Owner's Name Skip Shuler Address 1044 South Aurcrd Phone (209) 111$68828 contractor Rich Rer.t,Q;>, Address _ 11729 Langford License No, 273445 Phone(209)748-2-30 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION 0 Out of Service Veil ❑ f PUMP INSTALLATION fa SYSTEM REPAIR 0 OTHER t�on torf,ng Well (3+ So borings i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ''DISPOSfAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL ;OTHER,WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION OECIFICATIONS C1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation "? Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications if ("1 Public C1 Other n Delta Depth of Grout Seai Type of Grout I I Irrigation _Approx. Depth I ) Eastern Surface Seal Installed by .i ' Repair Work Done 0 Type of Pump H.P. I State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth it Depth Filler Material & Depth l ) TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I 1��INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other g Number of living units: Number of bedrooms Jf Character of soil to a depth of 3 feet: f df Water table depth SEPTIC TANK ❑ Type/Mfg Capacity '� 4 No. Compartments PKG. TREATMENT PLT.❑ f Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ;:Total length/site I FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS 11 Depth Size ��NumhBrr SUMPS L1 Distance to nearest: Well Foundation is 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 workman's compensation laws of,California." Contractor's hiring or subcontracting signature { 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 compensa- tion laws of California." The applicant must call for fall required ins pections. Complete drawing an reverse side. j + - M Signed X__ i�i--r `�L� ,.— Title: j Date- Jane 016 `32 Jane H. Gill QI', FOR DEPARTMENT USE ONLY PES Environmental , i Application Accepted by i Date _ Area f Pit or Grout Inspection byDate Final Inspection by 17�FC�RNA / Date p Additional Comments: �� k ^d,;,Gr�r� /I l; Applicant - Return all copies to: San Joaquin County Public Health Services, Eavirommental Health Permit/Services.! I1 ITS N, Ave., P 0 Box 2009, Stockton, ;CA 95201 CK J 25, AMOUNT DUE AMOUNT AEMITTED CASH RECEIVED BY A DATE PERMIT EH EK;.IAEV. s) �� X710 �i GD