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APPLICATION FOR PERMIT SAN JOAQUIN. COUNTY PUBLIC HEALTH SEERVICES-.,,, ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 -'V ''°" P O BOX 2009, STOCKTON, CA 95201 A i% rr COPY PERMIT EXPIRES 1 YEAR FROM DAM_ SYj'''` ry: ` ° )Aoi r,, y 6 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or Install the work here'id'deseiibed. 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 2-1 3 7 �� City dem Lot Size/Acreage T I� aC . e X 6 Phone .010, ;_ y Gla ?s9 3b b ' Owner's Nams AG'1�(1�, Ise r �J Q b ,moi / P t 11 Contractor V ,� 0 Address �G1j�.E' _ _License No.3 26 Phone TYPE OF WELL/PUMP: NEW WELL 0 - WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service-Well-,❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ enitoring Well O S"` -' DISTANCE TO NEAREST: SEPTIC TANK D00 SEWER LINES DISPOSAL FL . L E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .0 industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �^ EI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ SpecificationsI-r / 1'I Public C7 Other fl Delta Depth of Grout Seal Type of Grout --- �' rl I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by i Repair Work Done U Type of Pump H.P. State Work Done y`l� Well Destruction ❑ Will Diameter Sealing Material i Depth r Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitled if public sewer is available within 200 feet.) 1 Installation will serve: Residence_ Commercial_. Other m F Number of living units: Number of bedrooms Character of wii to a depth of 3 feet: Water table depth SEPTIC TANK. . ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT:❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F s SEEPAGE PITS I I Depth Sire Number j SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 ' Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 unifies 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 California." The applicant s1 11 for all usp4tions. Complete drawing on averse sido. I Signed Tithe: u""i � t Date: ff r V 00 FOR DEPARTMENT USE ONLY ` Application Accepted by-;CP_s c��, 'Date 4/" -r�`1 2 Area Pk or Grout inspection by Date Final Inspection by Datq� Additional Comments: Applicant - Return all copies to: San JoaquinCountypublic Health Services i Environmental Health Permit/Services y 445 R San Joaquin, P O Box 2009, Stkn, CA 95201 FEEINFO AMOUNTT DUCE AMOUNT REMITTED �ASNy/ RECEIVED BY DATE. PERMIT/NO. . EH 13.21 TREY,i i x sl EH 14.20