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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH r^yERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOC%TON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatill 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 San Joaquin County Public Health Services. Job Address -7.5.x.5' &,'e& A44t#ker taped p /1& City ��eck ia4 Lot Size/Acreage Owner's Name 9:219111C � AI S6- Af.AJ Address RO. A 574/.r Fief Phone 45W .oG. � R oiueza+J Contractor Address F�e 'H2S ��7]�—,4e A d/ 6Licen L7License No.26S5S6 phone U 40 d36 TYPE OF WELL/PUMP: NEW WELL Y WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well N DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 60 c DISPOSAL FLD. PROP. LINE -L;ff FOUNDATION �5' AGRICULTURE WELL OTHER WELL 50� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing a U Domestic/Private Ri Gravel Pack ❑ Tracy Type of Casing PvC Specifications S"A, 'yd M Public Ill Other ❑ Delta Depth of Grout Seal 7 Type of Grout Rir.G.r•iG G Irrigation �.Approx, Depth 0 Eastern Surface Seel Installed by P (.° E�-ar ��. Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION J1 REPAIR/ADDITION Ll 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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." The applicant mu t call for all re fired ins actions. Complete drawing on reverse sides. Signed �+"/ Title: •iv.0 f'r�.,c.. r�e�i1T Date: . 1142 ZZ57Z FOR DEPARTMENT USE ONLY , ,,�N Application Accepted by Date 2'7 •gZ- Area X4111_2 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 17,q 0 S // 5 445 N SAN JOAQUIN, P O BOX 2009, ST ON, CA 95201 INFO FEE I AMOUNT DUE AMOUNT REMITTED CASH VED By DATE PERMIT NO. . EH13.31[REV.Ir+sl I>'N $q•� 9.eo 5507 l�•?• 9y 2-3�✓03 EH A-211