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`...i APPLICATION FOR PERI[I T w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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 made in coetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3/ NOr( rf� i��"O k ce_ LILIke- City Lot-41 Lot Size/Acreage '7 ,KC 1C Owner's Name UfT 41t'K-r I KG • Address5_Zs GJ•7 1"'( -�T L 32.41 F,4z1 ee-*l d got r-,4c Z / Contractor unit ex lot'. 1KC • Address lf—ch' �o t&-f&. CAS 9514Z License No. G 0 7,T 2.0 Phon,61 IL). TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESJRUC ION ]&%ut of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O ° BOTH R O is Monitoring Well C] 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 Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Ois. of Well Casing n Domestic/Private 19 Gravel Pack O Tracy Type of Casing Specifications 1'1 Public n Other fl Delta Depth of Grout Seal Type of Grout Irrigation 40_�_Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction 19 Well Diameter 2 ff Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is �+ available within 200 feet.) �o Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of will 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 ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS ll 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 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 not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 st call for ad required inspections. Complete drawing on reverse side. 01 Si9qed «4.6ioe Title: ��°l°S f t f Date: 2 Q r de/A /IAht�7�� NA`�/� A. /�C . f FOR DEPARTMENT USE ONLY Application Accepted by M Date _/ r ( � Area C Pk or Grout Inspection by natalFinal Inspection by ate I 6 t�1 c 'S �iii 2quin 7� 7 Additional Comments: r Applicant - Return all copies to: San County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE ✓ INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. . EM t}24 d1EV.l i e s) I7 Q`J'� �(/� �b 0.0_� C.51 � EH 14.26