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APPLICATION FOR PERMIT -� SAN JOAQUIN COUNTY PUBLIC HEALTH SE ICES ENVIRONMENTAL HEAT TH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 20099 STOCKTON, CA 95201 R -M-9- DATE ISSUED (Complete in Triplicate) opplicatlon is hereby made to Baa Joaquin County ror a permit to construct and/or install the work herein described. This application is rade in CcWllanee with Ban Joaquin County Ordinance Ho. 549 and 1852 and the Rules and Regulations of San Joaquin County Public Health Services. 1 /� yy Job Address 24105 West f3�r1 j aurin 11o 'T nr City SrOGk4orl Lot Site/Acreage Owner's Nsma Che-vro a PrOdqclds Address 2,410 C41 nD &2vpi Phone tL/o S-q24Sekn ConlraclorJD /s !Dr' 77lllN-.�-w;mddress G �9� License filo Phone 707 'yS�Zr TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK 00-da"hlA SEWER LINES NA ^ DISPOSAL FLD . 14A PROP LINGt✓�� FOUNDATION2 7'S" AGRICULTURE WELL -NA— OTHER WELL2s'F"4• PITS/SUMPS INTENDED USE JqA TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-} Industrial O Open Bottom ❑ Manteca Dia of Well Excavation in Du of Well Casing 2 Art. n Do stesitc/Private 0 GG vat Pack L7 Tracy Type of Casing§'Cb' 14D pYL Specifications t -, I 1 Public (:}'Other n Delta Depth of Grout Seal S� T od nd .gray Type of Grout I I litigation ZER Approx Depth I 1 Eastern Surface Saul Installed by Dri lle.- Repair Work Done U Type of Pump — fN.A HP _ _ N4 State Wor Done " Well Destruction O Well Diameter N A Sealing Material i Depth PyefIand /a,-. ,.,,'�f Depth biller Material i Depth TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I 1 (No septic system permuted it public &*war is available within 200 feet I Installation win serve Residence — Commercial_ Other 40 umber of kving unlit Number of bedrooms hammier of tog to a depth of 3 feet Water tsbl© depth SEPTIC TANK ❑ Typo/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Dispotal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No 3 Length of lines Total length/sua FILTER BED 0 DutanGe to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws and rules and regulations of the San Joaquin County Home owner or licensed&pent It signature ownifies the fonovAng "I certify Thai in the performance of the work for which this permit is issued I shall not OmPLOY any person in such manner as to become subject to workman s compensation laws of California ' Contractor i hiring or subcontracting signature cantloeu the fosowtng 'I unity that in" performance of the work for which this perrrwt is issued, I shall employ persons subject to workman s compenza tion laws of Calllornta" The ant at call In r ins ions o ate drawing on reverse side Sig Title . -57�I~T /Q/s Date ':�151441 pro FOR DEPARTMENT USE ONLY Applic t Accepted by DittoD Area 35 0 f Pit or Grout Inspection by Date Final Inspection by Date Addltlonal Comments Applicant - Return all copies to San Joaquin County Public Health Services Eovirownental Health Perini t/Servicoo ' ti�Ct=1 Y CL' v Z ., Y y 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED 11YCASDATE PERMIT NO H �/� / q 13241M (rami ' ! 2rjz r'' I EOrD• I 6o333S ,Am r'