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APPLICATION FOR PRP.l11T 1.wl SAN JOAQUIN COUNTY VIRONHENTAL IIEALTFI DOIC IVIR 01�nan ^ P O BOX 2009, STOCBTON, CA 5 Omits,,„� , (209) 468- 3420 0 (Complete in Triplicate Application is hereby made to Sao Joaquin County for a permit to construct arid/ r I1This application is made in compliance with San Joaquin County Ordinance No. 549 and Joaquin County Public Health Services. A P,'J 14q- '210 -01 Job Address 8//00 E MAIKI S/. City cJ? � OC1 _ Lot Size/Acreage 112-A - Owner's Name/"1MDrzEW 14-1DU1-F Address P-0.6nX 42.3 STLY_IC7oti Phone 94,g_ 3040 Contractor 46��L�dress Ed.BOX 2231 CaQnoyA 9674.1 License No.G72 Phone -IS-S'9 TYPE OF WELL/P MP: NEW WELL O WELL REPLACEMENT [I DESTRUCTION Cl Out of Service Well O (JZ PUMP INSTALLATION O SYSTEM REPAIR CI OTHER A Monitoring Well p 52 . 7/`F.} t2 o /A/— DISTANCE TO NEAREST: SEPTIC TANK !Y[ SEWER LINES DISPOSAL FLD. i1/54 PROP. LINE --T' �r FOUNDATION IJAGRICULTURE WELLi✓1A_ OTHER WELLZVfI/ _ PITS/SUMPS AL"d INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Die. of Well Excavation " Dia. of� IPCc-i1 gN &Domestic/Private �✓//� Cl Gravel Pack ❑ Tracy Type of Casing_ �VoNe' Specifications M Public Other O Delta Depth of Grout Seal �uQ FAGF ,_ Type of Grout �c 1 00 CI Irrigation 4_0 Approx. Depth ❑ Eastern Surface Seal Installed by._Co.y�-Q_atr—/!P YMENT 0 Repair Work Done U Type of Pump H.P. - State Work Done Well Destruction O Well Diameter Sealing Material i Depth _ Depth Filler Material i Depth tll� TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION Cl INo Septiersxs�prjypjp f4tad�i��Jp'rT tic sewer is available 44??rY a�190r1 y1V t T a Installation will serve: Residence _ Commercial_ 0jher PUBLIC HEALTH SFf? It�ES 1^ ayn-- ENVIRONMENTAL HEALTH DIVISION Number of living units: Number of bedrooms �°tita ' ;1 Character of soil to a depth of 3 feet: -.. _,Water table depth SEPTIC TANK O Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. d Length of lines _ Total length/size . FILTER BED CI Distance to nearest: Well Foundation ._._ Property Line SEEPAGE PITS 1 I Depth Size ______ Number SUMPS L! Distance to nearest: Well .. Foundation _ Property Lina DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, anp_ rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I Certify that in the psrlormance 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 laws of California." The applicant mu call I r ell required inspections. Complete drawing on reverse side. Signed Title: �ouSGarAA22— Date: 3/Z9/1�ieg FOR DEPARTMENT USE ONLY 6 / Application Accepted by Date �� _ Area `� Pit or Grout Inspection by Date Final Inspection by Date —, ` �,� L�fl� OCL �- S, I5�HF.r Additional Comments: - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC H ALTH SERVICES o ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 S�jl FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO INFO _ - CASH fH13-241REV.I/K51 ��'j , �_ �00 �—