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APPLICATION FOR PERMIT j ] ia7r7� k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,�,.L� �E/NVVIRONNMTALL�HEAf�L�Ta DIVISIONI� � ` P 0 BOX 2009, STOCKIW, CA 9520J. }; ;N. (209)468-3447 - ' 9 3 BUIT EXPIRES 1. g,Z,R kROM PATH ISSUED :,I;tALTH (Completer ill Triplicate) F=.'`::li/;Ei�1�IC1 k Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made is =V14ance with clan Joaquin County Ordinance No. 549 and 1862 and. the Rules and Regulations of San Joaquin County Public Health Services. a,�4 per_yl .lob Address u�r�rtll7 oY RA 66d4! DgiLr � . _-- City SVCV-ICTbh! Lot site/Acreage /6,4� i Owner's Name .4h.vfCFIQ rWnl P,+4?rV las Address Il f", S( ixQi;ALSr S�vrx 1'vn,' Phone s" GZ Conlractoit1S>=�t3ttZ� F ��uA2i AddresO.523 AoriZ41-Cbi-S 7Q License No. to 7C phont'� I TYPE OF SWELL/PUMP: NEW WELL O WELL REPLACEMENT C) DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER S Monitoring Well O i' 4 50,E i3v t naty DISTANCE TO NEAREST: SEPTIC TANK 1YZA SEWER LINES 2-(70 DISPOSAL FLD.,—V/4 PROP. FOUNDATION S AGRICULTURE WELL/Y� OTHER WELL._ PITS/SUMPS A?-d4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Oia. of Well Casing .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing — Specifications i D Public rr Other ❑ Delta Depth of Grout Seal Type of Grout e04oAC2FT (� a 8GLL 11 Cl I(rivation C L Approx. Depth ❑ Eastern Surface Soul Installed by C0V 7', AC 7ri?- Rsoais Work Done U Type of Pump H.A. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Malarial i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION❑ REPAIR/AOOITION ❑ DESTRUCTION 1=) INo septic system permitted it public sit-war is f available within 200 lost.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fret: Water table depth SEPTIC,TANK- ❑ Type/Mfg CapacityNo. Compannrianis PKG. TREATMENT PLT.Q Method of Disposal i Olstance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size h FILTER BEO ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE iPtTS l I Depth Size Number i SUMPS t Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C1 I hereby csnity that I have prepared this application and that the work wilt 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 sub-contracting 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 taws of California.,, The applFicant m s a for wired 1 spections. Complete drawing on reverse side. ' Signed Title:G J504:,rr;a� Co4.:!Sc,,L-:Acv 1Date: U�7S+ jC1�1 3 FOR DEPARTMENT USE ONLY y�' Application Acce ted by Oate Area Pit or Grout Inspection by Data Final Inspection by Date i Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC XNALTH SERVICES ENVIRONMENTAL S ALTH DIVISION PERMIT/SERVICES 443 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERM31 NO. tH U-2s 11tfV.hrne :l.b fN 1 OZ�$ icy no Z 0,0/o,6 l