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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC REALTIi SERVICES ENVIRONMENTAL HEALTH DIVISION ` P O BOX 2009 , STOCKTON,;CA: 95201 (209) 468--3447.. . o - , PER911 EXPIRES 1. YEAR FROH DATE IUXM (Complete i-n Triplicate) P�,.. � .. Application is hereby made•to San Joaquin County for a permit to construct and/or install the vor% herein described. „This } appllcatlon Sa is made in covItLnce vith n Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulatlona of'San Joaquin CountyPublicHealth Services. k Job Address .5�21 ( •Fre wla yt Cily c—M Lot Sise/Acreage O'X 3 Owner's Name I ) 6eo!:Ue LP_,b,;L l - Address L.Q•ffCyX G7.S2�I Phone ._� Contractors c—im M &IJ00-ahesoAddress r t )t incense NWQ7-Zi-F Phone •87/Z j TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT 0 OESTRUCTION .0 Out of 4Service Well Q PUMP INSTALLATION O SYSTEM REPAIR, C1. -" OTHER, O Monitoring well, DISTANCE TO NEAREST: SEPTIC TANK Y1A SEWER LINES 200f DISPOSAL FLO. XA PROP. LINE FOUNDATION r AGRICUL LTURE WELL- OTHER WELL LIA PITS/SUMPS"&e-+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _f0 4"___ - Dia. of Well Casing %ComestielPrivals Gravel Pack ;C7 Tracy } Type of Casing_ L Specifications, u ¢a 1 0 Public ['I Other ❑ Delta Depth of Grout Seal S;+$2 6 ��` Type of Grout° CJ litigation Jr, _Appro:, Depth ❑ Esstern ;Surfaca Saul installed by CONC>vt/ Repair Work Done 0 Type of Pump w H.P. - Stats Work Dona Wall Destruction ❑ Well Diameter Sealing lateiial,i Depth a C»= n Depth Y11ler Material ti Depth TYPE OF SEPTIC WORK:" NEW INSTALLATION D REPAIAIAOOITION Ll DESTRUCTION 1=.1 (No septic system permitted it public,sawar is available within 200.leet.l Instillation wUl serve Residence— Commercial_ Other Number of living units: Number of bedrooms Character of &all Ao a depth of 3 lest: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments i PKG. TREATMENT PIT,❑ "' Method of Dim _ sposat- Distance to nearest: Well Foundation Property Line P LEACHING LINE rC1 No. fi Length of lines' Total lengthlsiie FILTER BED n ::Distance,to nearest: Well Foundation Propeny tine -•`, �+ 4 SEEPAGE PITS - 11 Depth sirs Numbor ' SUMPS Ll Distance to nearest: Well Foundation Property Tins , e DISPOSAL PONDS Q 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 ruiss and regulations of the San Joaquin County ,6 - �+ Home owner or licensed agent's signature candles the following:"I csnify that in the performance of the work lot which this permit is issued; I shall.not employ any person in such manner as to become subject to workmen's compensation taws of California." Contractor's hiring or sub-contracting sig.nalute +. certifies the following;"I csnify that in the performance of the wort.lot-which this permit is issued.'[shall employ parsons subject to woikmin•a compensa- tion laws of California." i. p The applicant mcall all raq r inspecsiont. Complete drawing on�rsiverse-))xfJide. Signed % Title: / t/K,Li I n ti1. Date- FOR ae:FORR DEPARTMENT USE ONLY 1 Applicsllon Accepted by ___,� _. (l],XI/ be,* Area Pit or Grout Inspection by "':Date ' > Final Inspection by - 'Dau _. AdditlOnd Comments: Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC.HSALTH SERVICES" ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES `F 445 H SAN JOAQUIN. P O BOX 2009. STOCKTON, CA 95201 y 3sv � 1- INFO FEE AMOUNT DUE AMOUNT FtEMtTTEO' CA5„„ AECErvEp BY DATE PERM17'NO., , EH t3711�£V.err frLU� .+ • to :r.� « ,.Y� .