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APPLICATION FOR PERMIT SAN XAQUXN COUNTY PUBLIC HEALTH SEYVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT P 0 BOX 2009, STOCKTON, CA 95201 RECEIVEQ o (209) 468-3447 !PP I fcrf O PERMIT UPIIRE95 1 YEAR VROM J2ATF.s ISSUED SAN JOAQUIN COU NIT (Complete in Triplicate) Ev)UBLIICHEALTH SERvr{!)% AppCs is hereby made,to San Joaquin County for a permit to construct and/or install the wor1i' Y��cfl� i1�1 �(C�I( jis Oppis made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joanty Public Health Services. Job Address f� C Cit 6h _ Lot Size/Acresg y 4�2lU 0 Owner's Name &P 0 t coo. Address Zd 2-L T aS_fac.� Vvir � f_ �U� Phone k. 631-6 0) ��,. �� ,, 4,�atsz�,t'� p� CAA, C--51 L"3�o �� Contractor amu- c0 -Address LLO 2- ��►�"I x1 Am, License No. L%"33Z6 -Phone 46-1-- 2.71Loj TYPE OF WELL/PUMP: NEW WELL'W WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR F:) OTHER O Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK _.NA SEWER LINES452 "M __ DISPOSAL FLO. NA PROP. LINE 1 10' FOUNDATION !L 32 r AGRICULTURE WELL�$W r OTHER WELL 2',"' _ PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Fl Industrial U Open Bottom 0 Manteca Dia. of,Well Excavation,--l—"" �� - --vfx si Well Casing U Domestic/Private Gravel Pack 0 Tracy Type of CasingS4L_11O vC Specifications eA ti + P%4 CJ/011irv, 11 Other 0 Delta Depth of Grout Seal S�a� 't rout ! Type of G _ 11 Irluaron J Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done __ Q Well Destruction 0 Well Diameter _ Sealing Material & Depth Depth Filler Material i Depth TVP SEPTIC WORK: NEW INSTALLATION!1 REPAIR/ADDITION M DESTRUCTION CI fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: dance_ Commercial _ Other Number of living unita:- f bedrooms Character of coil to a depth of 3 feet: er o _. Water table depth SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well ation! Property Line tEACHING-LIN Cl No. & Length of lines _ L Total length/size_ FILTER BED C. Distance to near Foundation Property Line SEEPA pth Size Number _ SUMPS LI Distance tonear e10[ I foundation __. Property tine DISPOSAL PONDS 0 "_� I 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 Sen 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 applicaRt mull c 11 for all r ired ins ctions. Complete drawing on reverse side.4117 Signed ) Title:2 1—_ _ _ _1 ` 1 'lel _ Dot, �aw nrA C., F DEP ENT USE ONLY c- Application Accepted by Date � J _� Area Pit or Grout Inspection by — _ Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCXTON, CA 95201 FEE CK If INFO AMOUNT OUE AMOUNT REMITTED_ CASH RECEIVED 9V DATE PERMIT NO. E'+ I3I/1/1rV 17,00