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{ APPLICATION FOR PfiRYIT 61) 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 (Complete in Triplicate) Application is hereby made to Sm Joaquin County for a permit to construct and/or install the work herein described. This application Ss made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublic Health Services.. Job Address _[��lG/ � /iJ�'�, /1� /City ZO1 "A Lot Size/Acreage Owner's Name (�y/LiT�is��e�t/Tr T/CS Address ��-SyYcypf��-Xo�.""> ✓��C Phone / ' 2 3 T Contractor PG�� IOM71-po Are— Address//Be yRNod License No.ZSj b Phone � ' ' 7 TYPE OF WELL/PUMP! NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public F1 Other n Delta Depth of Grout Seal SG _ Type of Grout I I Irrigation ZOAppros. Depth I I Eastern Surface Seal Installed by � wl7�i �it Repair Work Dona ❑ Type of Pump H.P. State Work Dona_ Wall Destruction ❑ Well Diameter Sealing Material L Depth Depth tiller Material a Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it pudic sewer is available within 200 feet.) Instillation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth sof 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal , Distance to nearest: Well Foundation Property Lone LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to name Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hews 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 Hone owner or licensed agent's signature certifies the following: "I conity that in the performance of the work for which this permit is issued, I shall not f employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sutzcomracting signature certifies the following:"I unify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa• tion levee of California." The applicant myst call for all required inspections. Complete drawing on reverse side. Signed ) , rr^ S Title Date: FOR DEPARTMENT USE ONLY ST L I • �� Application Accepted by Dna �•� Area Un( PR or Grout Inspection by Date f a6 Final Inspection by /Date/ r T2- Additional comments: — (le C1MnXcL �a43k Rctc ( G. Q. APN $1-2100-2f i Applicant - Return all copies to: San Joaquil County Public Health Servlcee - Environmental Health Permit/Services 1•`Ev 445 N San Joaquin, P O Box 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EN ti.:.laEr.,,,er oo . o� 4q0 -2Z•YL 323 EM to-orf f