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AMW APPLICATION FOR PERMIT 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 `t (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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health /Servicers. Job Address r .a X-C f 4, t City /_air Lot Size/Acreage '*ZS W• Tibe.ul Tf Owner's Name " IKf• Address rt"s�� . CA 9f2?� Phone6&1s�Z �zIf/ 3241 F. L/•,•S 1P. PC 2 Contractor�ylhri /. M!- Address �e. #LC.<• G1�irteoL'4 �$}4Z License No. �'�232o Phan - Wa-'NS's TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ B _5.44,16 +•l$e,-16THER .9 3 Monitoring Hells DISTANCE TO NEAREST: SEPTIC TANK y SEWER LINES "t"' DISPOSAL FLO. sea PROP- LINE >Se 7' FOUNDATION �Sa AGRICULTURE WELL � OTHER WELL76-12a PITS/SUMPS -Sb1V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- S• r `~ y ` �"� � ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 ra. Dia. of Well Casing rw [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing sd i, ^c Specifications C4 40 1"1 Public TA Other NN►,4er't (-1 Delta Depth of Grout Seal 42 4* Type of Grout CA "Gar► .. I I r!.Irti ation r g Approx. Oepf I I Eastern Surface Seal Installed by dirl/e.- ~` 11L {los, 4" r Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth 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 20.01ai_I------ Installatio 11 serve: Residence_ Commercial_ Other _r--- Number of Irvin ts: Number of bedrooms Character of sod toa f 3 feet: �yWga�rter table depth SEPTIC TANK O Type Capacity 1dC i' Zints PKG. TREATMENT PLT.❑ FJ1* @osal Distance tQ crest: Foundation Prop�t�Li LEACHING LINE c. & Length of lines Total Iv FILTER BEd ❑ Distance to nearest: Well Foundation ..��,, 'n4PV(H�J rEr 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 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 must call for all /required inspections. Complete drawing on reverse side. Signed X/(rSAs.,.��- (.(��ra•lly Title:1ysl�Ast I L14 LO �/G Date: �j� �k✓r/•r1/rt Kt-1 ~� lice�F,OR PARTM LY 7Application Accepted byyi ww Date I 2 Area Ph or Grout Inspection by Date Final Inspection by a; t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services o 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201CK dd INFO FEE AMOUNT DUE AMOUNT REMITTED (CASH RECEIVED 8V ii —DA/TE/// PERMIT NO. EH t3-24(REV. i n>> -/ . }(' Y..� �(13 / /,� /,� EH u-2s ( rJ ( III{y ( vCJ -(