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APPLICATION FOR PERMIT e SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S ENVIRONMENTAL HEALTH DIVISION p < \ r P O BOX 2009, STOCKTON, CA 95201 1Z } (209) 468-3447 PERMIT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6588 West Sacobs Rmael City 54 k-" -Lot Size/Acreage $0i X 50r Owner's Name Lnecy Pt_1�r'1 F+. M Address GS88 Wee+ Taco6s �Raad Phon 43-707 Contractor / f r l 1 _LdLAddreSS ! 1 A 1J P /I eA License No. [.y1 '73o phone / TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK X100' SEWER LINES 1 1&0' DISPOSAL FLO,u�A_ PROP. LINE 4912 FOUNDATION SO' AGRICULTURE WELL N/A OTHER WELL2100' PITS/SUMPS b" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Die. of Well E.cavation Dia. of Well Casing Lill k O Domestic/Private 0Gravel Pack ❑ Tracy Type of Casing NSA Specifications LVA �,! M Public yv Other501130/04! Depth] Delta De of Grout Seal SmInit s: DEOILL , � P Type of Grout NS#et G1R4EWT ❑ Irrigation 1010ji&q5 Approx. Depth ❑ Eastern Surface Seal Installed by__ N/A Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material a Depth Depth Filler Material a Depth F SEPTIC WORK: NEW INSTALLATION JD REPAIR/ADDITION 17 DESTRUCTION CI (No septic system permitted if public sew available within 200 feet.) 6- Installation will Residence_ Commercial_ Other „n Number of living units: __ Number of bedrooms ��V(('',11 co Character of wil to a depth of 3 feet: or table depth W SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well anon Property Line LEACHING LINE L1 No. 6 Length of lines ngth/size FILTER BED CT Distance to at: Well Foundation Pro Line SEEPAGE PITS Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line (d D AL PONDS O r}V� I hereby unify 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 Sen Joaquin County CO 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'.compensa. tion laws of Californ1 .11 The applicant co r to red inspections. Complete drawing on reverse side. \�) Signed 9 n Title: 4,<, JZ...a Date: i-L n�DEPARTM ENT USE ONLY Application Accepted DY - yr`e"(w'( ,//.`/ J`,,� Date //v -�U Area C;2zl-` Pit or Grout Inspection by Date Final Inspection by� /� Date 11-14"-7c Additional Comments: Applicant - Raturn all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON, CA 85201 FEE I AMOUNT DUE AMOUNT REMITTED CK CI 1:1 aV DATE PERMIT NO. INFO (`� �yj�� C H A �J EH 1Y1N 111EV.vsm —\ ` _ `J� _ •� =_ �� —O �L� b/. EH:4M