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APPLICATION FOR PERMIT SAN \-,,AQUIN COUNTY PUBLIC HEALTH , VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is mde In coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _139 SOV7-# Cf J-rEA, STrPEC:7' City5TVCKT0N Lot Size/Acreage"/b.900 W F'r Owner's Name C*6VA 0tJ U•SA, Address 71 D` BOX 500*.51f,,)/RIIA101V Q _ Phone Contractor � F 9C14 �RILLIA/§ Address 0 N �iCts6.&485165 -Phone 5_10 1 ?r TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT n DESTRUCTION O Out of Service Well D PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring 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 D Industrial O Open Bottom D Manteca Die. of Well Excavation Dia. of Well Casing 2" C.] Domestic/Private Gravel Pack D Tracy Type of CasingSc&&D ALO PVC Specifications " I'I Public n Other n Delta Depth of Grout Seal 017-6 31, Type of Grout TCS E.✓T I I Irrigation 60r Approx. Depth I 1 Eastern Surf�ce Seal Installed by LL Repair Work Done U Typo of Pump /J/A H.P. wl A State Work Done —A) III Well Destruction O Well Diameter 2-IHIGN Sealing Material & Depth 6,40 -� 01-ro.3/z EC15 Depth ^'(60 FT Filler Material b Depth 54Ab eA41: 33'TO &_Qr$yS TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of colt to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 Homo 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 conificts 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 componss- tion tows of California." The applicant must call for cfl required inspections. Complete drawing ort reverse side. Signed x -7-- //)�— ��TY) Title: /f.SSO L/,-f7-F Date: F EPARTMENT USE ONLY r �� Application Accepted by DateArea Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: 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 I CK RECEIVED BY DATE PERMIT NO. INFO CASH . EM 13-241REV.tin51 EM 14.2! L