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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 . . PRUITEUIRES .._.YEAR VRA (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or ins t j�et' Fk heAtip d r}�e This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1662 and ""F/ � 1I-d K� atidaa! of Ban Joaquin County Public Health Services. ,��^ �•/��y� �/ n��j,�9�" Job Address 14' A/• GSL JJQICI�.I�LJ Jt�.f,CDAlsI �� CitY� � Lot Size/A r.6, Owner's Name 1-I K.S. WCG) �0 V,0 Addre�a �� -j=1��'sl.�' !`!r "",r".." Phon'el WE _ S �s �/ S!�-�r✓ qs2� Contraclor DCA("�^ 4' cess 2425 45. /cif 7 , License No. S/ �•'Io�Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION 171 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 SOIL 110 �2 Monitoring 21l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _Ll��_ DISPOSAL FLD. PROP. LINE 2 �tr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS If/Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excarva7tian Dia. of Well Casin Z�4� "Domestic/Private El Gravel Paq D Tracy Type of Casing`(_�G_ _.___ Specilications U P"hlic Other h,�prt�Delta Depth of Grout Seal z N GI hn anon --+------- 7y a Of Grout_ t) __ A epth Eastern Surface Seal Installed by_ _ �X 4 Repair Work Done C3 Type of Pump H.P. State Work Done _ Wolf Destruction O Well Diameter _ Sealing Material i Depth Depth Filler Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION r_1 fNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial — Other Number of living units: Number of bedrooms Character o1 $all to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity_. _ No. Compartments _ PKG. TREATMENT PET. C) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED (_I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Lt Distance to nearest: Well Foundation Property Line _ Q DISPOSAL PONDS ❑ I hereby cenify 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 rogulations 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 sub-contracting signature certifies the following: "1 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 Californla." The applicant must call for a fopuifed ins coons. Complete drawing on reverse side. / Signed X Title: Sp�I�C�" 6- a c,1 Date: DR DE RTMENT USE ONLY yy Application Accepted by Date ,(�s� 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 2000, STOCKTON, CA 05201. FEE AMOUNT DUE AMOLINT REMITTEDFCC:A'S�H _ INFO RECEIVED 8v DATE PERMIT NO. " I3 Into „-„ _� � , . r.,