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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3,W,3y-�L0 PEMIT EXPIRBS 1 MBAR VROM DATE I-"-L= (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 Ban Joaquin County Public Health Services. D Job Address .35� "'`"'� ram 1� /��' City Lot Size/Acreage Owner's Name Souza Address Phone Real f� .35 &s� /eA V. T�� 835-833 ffll 3233/Fr+zmald Sf. Contractor We_Aay IaT �1'l�'1�_ gddress �G>7(i�to Car�ot'A +� 95�`��License No.S5` 9Z Phone(,?/%/ X38"727( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well r DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES 5' DISPOSAL FLD�* -/0100'PROP. LINE 5 r FOUNDATION �� AGRICULTURE WELLy102__ OTHER WELL 612 PITS/SUMPS ?L� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ i0 Dia, of Well Casing CJ Domestic/Private Cl Gravel Pack X Tracy Type of Casing PVI—' - Specifications R Public 1-1 Other ❑ Delta Depth of Grout Seal "fZ_3 t5 40 MfActv'pe of Grout&t&'r� �._. �CI�r gatictn rr��-ttqa —Approx. Depth ❑ Eastern Surface Soul Installed by ai�V„1forDefie U Type of Pump I✓v►?2 H.P. State Wofk Done Well Destruction O Well Diameter-- Sealing Material i Depth rS2 fo+.r tsars o rfe� eiriez Depth '' 7a Filler Material A Depth-`3 ,S4M *Pr ^^3.��eW sQ TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/AODITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial— Other Number of living units: Number of bedrooms SAN COMM-PUBLICH Character of soil to a depth of 3 feet: .______ a T,pgRONM,,.,TAa��(]112iIOVW SEPTIC TANK ❑ Type/Mfg C Tac;I I A. mllpartrnents PKG. TREATMENT PLT. ClSJF Joe1 pERJMtlod of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE L1 No. 8 Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 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's compensa- tion laws of California." Roy rG AA06lt �NG• The applicant ust call for all requi d inspections. Complete drawing on reverse side, $3 W./"a cr.C"La 5 e 17, Signed Ti[ie: g. GT ��! Ih�� st•c�fo;CO ?6107 Zoo �/ T USE ONLY EPA Za5 1t76-/63S" Application Accepted by Date 71 Area Pit or Grout Inspection by r a,C � iData c/ Final Inspection by �' Date " q/ Additional Comments: �'� Z' % f CLhK Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 808 2008, STOCKTON, CA 85201 IEEE AMOUNT DUE AMOUNT REMITTED �ryA`.S0 �REE'CCEIIJVED BY r� DATEPERMIT 1 //�PERMIT'N0. . EH 13.23 tREV. n SI SR!' [ 1✓ + f _ Lam. Lo-2_� 1 J ! ��!IS EH 13.26 tCCL��