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APPLICATION FOR PERMIT SAN AQUIN COUNTY PUBLIC HEALTH `S`JkRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERHIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby suede to San Joaquin County for a permit to construct and/or install the work herein described. This application in rade 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Jonquin County Public Health Services. C� �/ y ss-- City 4zr Job Address 12 S.w7't-� �C�,,7ej` T� y� � oK Lot Size/Acreage Clpl9 1 y drd� Owner's Name l��✓/�o+'r �/.ti le cO. Address ir��/Cu-t rr�/t - �21n P4,'�Dij Phone �/0 ?1fJ,- �s / Contractor arl �X o �td'V a Address 1 �C 93 �4��- License No�7jP24G Phone °7 ` -'�9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ _ OTHERS , Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. Ser / Wp-.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other n Delta Depth of Grout Seal r_r�-pr- Typo of Grout I I Irrigation —Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done U Typo of Pump H.P. State Work Done�r 'j� 4l K S Well Destruction O Well Diameter S�' Sealing Katerial G Depth t j&,-r C r y"e,"r -R r6,-- 0 g Depth `X ` Filler fhterial b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will servo: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sob)to a depth of 3 foot: Water table depth (A SEPTIC TANK. O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to noarest: Well Foundation-__-- � Lino LEACHING LINE ❑ No. A Length of lines II FILTER BED ❑ Distance to nearest: Well Foundation 3PR 2- proMLino tLbpN� i SEEPAGE PITS ( I Depth Size POS ' J✓TY SUMPS LI Distance to nearest: Wall FoundU 0��MFNTA L'Qomottv'Ifi,l �� DISPOSAL PONDS ❑ �t U I hereby cortify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules end regulations of the San Joaquin County Homo owner or licenaod agent's signature cortifics 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 monnor as to become subject to workman's compensation Iowa of California." Contractor's hiring or sub-contracting signature cortifios tho following: "I cortify that in the portormancg of the work for which this pormit is iwuod, I shall omploy parsons subject to workman's compcnsa- i�r tion laws of Celifornlo." The applicant must call for 1:71 required inapgctions. Complete drawing on reverse side. �J �i Signed X �i �Co- Title: 1,45s, u FOR DEPARTMENT USE ONLY Application Accepted by Data ° Area Pit or Grout Inspoction by Date Final Inspection by Data Additional Commonta: 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 INFO AMOUNT AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. FEE. EM13.21 tttEV.1in5) EH 11.23 l.! ! ✓ ✓'( G