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APPLICATION FOR PERMIT SAN AQUIN COUNTY PUBLIC ALT$j ENVIRONMENTAL HEALTH DIVISIf3N 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCBTON,, G4A:1J�01 PERMIT EXPIRES 1 YEAR FRO4 6ATttSSUED (Complete in Tripl C��IItt`e�/) Application is hereby made to San Joaquin County for a permit to constru t ddd/br'Sn,1 •�- ..,.w h 1-ed. This application is made in compliance vlth San Joaquin County Ordinance No. a ne of San Joaquin County Public Hea'ltth' Services. / Job Address f/EZ 7 C{ C Gw S4"-c,2k City / ///JJJ��L�� .i�f Lot Size/Acreage Owner's Name j %Q-u.- !4. 1'0 V-- - Address 64 &,� 1'/JT-4 U/ F ,a Phon,60) 5i'�7'��3 9- Contractor Address Z2�( ,/ itl� License ND ��4r �O Phone .5,U •.571+/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ � / 7-1 1" DISTANCE TO NEAREST: EPTIC TANK SEWER LINES DISPOSAL FLD. PROP. INE / FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial If Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications //��" I'1 Public fl Other fl Delta Depth of Grout Seal Type of Groutr,a. G J^ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by nil Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 4 Depth X Depth .-� Tiller Material a Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is available within 210 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soli to a depth of 3 fast: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Companments ^_ PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ( _ \1\ SEEPAGE PITS 11 Depth Sirs Number .`� SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ \�\ I hereby unify 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 reguistions of the San Joaquin County Home owner or licensed agent's signature ceniflea the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in won manner as to become subject to workman's compensation Iowa of California. ' Contractor's hiring or subcontracting signature oenifiss the foaowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compen". tion laws of California.- The spotican[ st c I(' r all qu d'' s(s eti rtf. Complete drawing on reverse side. Signed Title: <�// Date: 7FOR DEPARTMENT USE ONLY�4 ;WP� �/ Application Accepted by Date /� ` 3 Area Ph or Grout Inspection b/r 7� Date r1 fs Final Inspection by' Den Additional Comments: L� z2- � /1yt) Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED fly INFO AHCCASH�j / DATE PERMIT NO . EH 14.26 IREV.ileal ✓— 3 ! 5� ` P Z, ? EH 142a