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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 . (209) 468-3447 YEAR tROM DATE in Triplicate) 4A N4 (Complete P /RO ,� Application is hereby made to San Joaquin County for a permit to construct and/or inats ��/*I heaiy de5�,r a This application is made in comliance with San Joaquin County Ordinance No. 549 and 1862 and t nad 17 ti of San Joaquin County Public Health Services. 9 /,�', Job Address 141 AZ 47)6leApotat• City Lot Size/Acrh?, ` , /I,/� � � 1 `` 475 S Owner's Name f4eS. WING iee �O �� nss �� Nr STaG��r Phone 5rVCJCT5 d 45 CantraclOr S - _ DeAw �tess 24:S �• License No. S/ ; .r2bLPhone Ila TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1SOE<.. GORW64A 1(J Monitoring 211 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES It)' DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TIONS t� ,i n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing **Domestic/Private ❑ Gravel Paci 0 Tracy Type of Casing PVC, � Specification s— M Public Other __, LL�� Delta Depth of Grout Seal 2' Tye of Grout G Irrigation _Aeptr h Eastern Surface Seal Installed by S�� Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction © Welt Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION G 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.C1 Method of Disposal Distance to nearest: Well Foundation ny Line �1 LEACHING LINE Cl No. b Length of lines al lengt size FILTER BED n Distance to nearest: Well Fo n Property Line (+� A SEEPAGE PITS I I Depth Size Number 0 SUMPS Ll Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ 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 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 of subcontracting signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m at call for a re fired ins coons. Complete drawing on reverse side. / Signed Title: S rb, �'t4�Q Date: 2yC OR DE RTMENT USE ONLY / Application Accepted by DateC Pit or Grout Inspection b , * 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, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED 1 GASH RECEIVED HY DATE PERMITNO. INFO tH,a•34IItEv.I,M„ ,pU M4y5b y s��/ /07-: EN;4.311