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,1 APPLICATION FOR PERMIT SAIr'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED g ,,, Ll (Complete in Triplicate) Appllcatiolp_lIn hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in Compliance vlth San Joaquin county Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Publ e X l h e v ces. its �/A�'✓n[2d�4�1� w�/s Ti's cry/s//�4 a d,l�/✓d. Q (T Job Address 406nj Ovl d'J4z[ -.131-/20-L14 7/{,40kre City �r N Lot Size/Acreage �` ll,ff e L % W.We%/1 A� L L Jan19Cnerscor 64 y1110E Owner's Name A•W,�C�fin, Address �,Rq MQ✓I(�FT .s�'..�U[7E•�7�� Phone IS- 9-77—IROD �_� CS!2373 htog- • Contractor � Address P� . /1X �9Z License No. Phone — TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ - -- PUMP INSTALLATION n�G"�.� SYSTEM REPAIR ❑ - - OTHER ❑ .Monitoring Well LJ , DISTANCE TO NEAREST: SEPTIC TANK �yL_ SEWER LINES .•C,SU�f DISPOSAL FLD.2-5-0 PROP. LINE [i- FOUNDATION AGRICULTURE WELL 10—OTHER WELL 'S O — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — ---- _. { Industrial 0Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r ❑ Domestic/Private L[ Gravel Pack ❑ Tracy Type o Casing Specifications J .r CI Public 1:1 Other L' Delta Depth Grout Seal 62LLTypa of�\Grout M Irrigation /YCADprOx. Depth DIEastern S acs sal Installed by as QTEr L.JCi y✓�� Pepsi( Work Done ❑ Type of Pump - ! f"b H.P. State Work Done �n L! Well Destruction ❑ Well Diameter Seal 1 Maur Depth Depth 74,11ir Materi a p TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REP IR/ DOITION DE RUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ at Number of living unite _ Number bedrooms Character of soil to a depth.of 3 last: Water table depth SEPTIC TANK ❑ rixwn,', Capacity No. Compartments PKG. TREATMENT PLT.CI Method of Disposal to earest: (Wall Foundation Property Lina LEACHING LINE ❑ o. g Length o lines Total length/size FILTER BED ❑ istance to nearest: Well Founda ' Property Line SEEPAGE PITS f I Dept Sire mbar SUMPS LI Distance t Barest: Well Foundation operty 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 ceniries 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 followin : "I certify that in iM performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion la amo The s*llicar all re " ns ompl adrawing on�r �p�rjs/q s]clo. -7 p Signed Xao ,/'�-�J Title- _(..-,(%'- ///a.r/r�KE,«Y Date: l - / — 7 I OR DEPARTMENT USE ONLY ' rl Application Accepted bAby � � =DEPART Date \—O� ` 1 Area Pit o Grout napection Date Final Inspection by Dats Additional Comments: k -/ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f�I /p��a 3• 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95203 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. En 112E(REV.I,nll EN 13.24