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APPL I CATI CSN IIPOR PERM I T SAN .T$A UIN Q COUNTY PUBLIC HEALTH SERVICES • FNVIRONldENTAL HEALTH DIVISION P C BOX 2009' STOCItTON, CA 95201 j (209) 468-2*4.9,3`�-,;L0 R '! .REMIT E%PI 1 YEAR F`RO1d DATE ISg3,TJm { (Complete is Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. application is made in compliance with San Joaquin County This nanOrdice No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 11 ' Y-Gl? �1 Job Address V /�� ir Cit y ` Lot Size/Acreage Owner's Name Souza Realf �S CC Address ' l S1 1 l � �35� 3 Phone � azimaf �rr�f�i� SZ33 1jVes / Fr z xAld 51-. _ . Contractor Address I041i' oto 60r7.'( 957WILicense No.55y? C57phone ,, 638-7276 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ i� PUMP INSTALLATION ❑ SYSTEM'!REPAIR C] OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S' r .E DISPOSAL FLD//��t7a0�PROP. LINE 5 �> FOUNDATION ��r AGRICULTURE WELL-1_L,2 L OTHER WELLA PITS/SUMPS ?&00' INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRt1C11 TION SPECIFICATIONS n indusitrial C) Open Bottom ❑ Manteca Dia. cf Well Excavation D ~ Dia. of Welt Casing „ U Domestic/Private 0 Gravel Pack X Tracy .Type of Casing Specifications �} Q Pubfie !:] Other I. 13 Delta Depth of Grout Seal "rZ-3 GrJ 3ftFA Beulot•t7f8 ' ype of Grout o� �r��t� -- Pprox.',Depth [I Eastern Surface Saul�Instauad by v epau a e U Type of Pump H.P. State Work Done _ 4 Wall Desttruction ❑ Well Diameter Sealing Material i Depth r621+#a1l arlil 1J DeZ pth O r FSller Material L`Depth#3 SQN l�f �.3,/(�QfoytJ SF c2 TYPE OF.SEPTIC WORK; NEW INSTALLATION 0 REPAIRIADDITION ❑ DESTRUCTION Cl IN septic system permitted if public sewer is available within 200 feet.) Installation will servo,, Residence Commercial____ Other )' Number of living units: Number of bedrooms_,SAINJOAQUIN CO UN�7 Character of soil to a depth of 3 feet: " .. PUBLIC I� g � i� e SEPTIC TANK ❑ ;i Type/Mfg 's C Tachy No.LOmpartments PKG. TREATMENT PLT. ❑ 1 A T i j li L .i ER tTd of Disposal Distance to nearest: Well Foundation Property Line F. r LEACHING LINE C1 No. A Length of lines Total length/size FILTER BED C7 Distance to,nearest: Well Foundation Property Line 1'P ;� SEEPAGE,�PITS III Depthii Size Number SUMPS t l !'Distance to!nearest: Well Foundation "" Property Line DISPOSAL PONDS 0 i 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 j 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, f 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: "f certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa tion laws of California.,, r r { ci �O r�-/vA lt?c. The applicant ust Call for all iegq d inspections. Complete drawing on ,revers�eLside. _i Signed Title: f 'a* GT 5" I;7 st��*J% CA 15?07 17 Date: 74 j; toy #76 '3S EPA T USE ONLY Application Accepted by ' Z:- Date ��_ Y Pit or Grout Inspection by ._� // � Dated-�1- r•inal Inspection by " 11 �I . Date l.J h ' ,� Z / Add'nional Comments: i 77 �*".�"�- If Ej - Applicnat``- Return aLl copies JOAQUIN COUNTY PUBLIC HEALTH SERVICES f. ENVIRONMENTAL HEALTH DIVISION PER' WIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009,:-STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTEDCK if �\ INFO CASH RECEIVED BY DATE PERMIT'NO.