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APPLICATION FOR PERMIT 4 • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby mode to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with SanL Joaqu�i!n�Co�unty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County,,PJJublic Health Services. 'Aw (.7v '� ,Ir101'71}pyl� L"e'l L�S� Job Address 4171 oyr, yr M/at1 City JSJ6c"On Lot Size/Acreage pp `�, L /1 !� to Owner's Name Rty� P/t'Ur L] L-Oh'IP9?1 Address ?I) BOX 5,91 �- R1 o U r54A Phone Contractor VYAddress 7 /1-icense Phone 3Ao TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM� REPAIR ❑ ',/,1�OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK AJIA SEWER LINES DISPOSAL FLD,e _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing nE. 19 Domesti Privet ❑ Gravel Pack p ❑ Tracy Type of Casing i V C Specifications I') Public ❑ Other .9 Delta Depth of Grout Seal �3r) v Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Df,Iley- Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material a Depth \ V' TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearer: Well Foundation Property Lina LEACHING LINE ❑ No. 8 Length of lines Total length/size ,II FILTER BED ❑ Distance to nares,: Well Foundation Property Lina SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ((( DISPOSAL PONDS ❑ 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 r 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 notIq employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub- omrscting 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 mu call for all r S/+yed/�mspections. Complete drawing onlrover" side. (' Signed x �/'�/ilk ��6GGa, Title: 4C0/Doff Date: FOR DEPARTMENT USE ONLY Application Accepted by Date " ` 3 Area Pit or Grout Inspection by 0 Data t� Final Inspection by /I Data Additional Comments: `5��"^ Com` C' O/` Applicant - Return all cop es to: San J quip County Public Health Services Environmental Health Permit/Services � 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 [PY35. O I FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH �/ �/ 9 . EN ,12.IREV.irxsl EN ll.as MR �/ �/ -// —/3 ..3