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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201(209) 47 0044 pRIT EIRES 1 YEAR YEAR SROM DATfi ISSUED Rp (Complete is Triplicate) Application Is hereby made.W San Joaquin County for a permit to construct and/or install the Work herein describe This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re Is I no f San Joaquin County Public Health Services. / Job Address 3333 lfJ_ H4MA4oJ 14vIP City <Aex-44 Lot Sise/Acreage i /� Owner's Names Nmom Address 9 jl.• 401 /��6 K/..W/f. &01( ; Phone Contractor i/PfA Lt ljfdj4f�Y/!f Address 413/ Al hirwP /�/eN&L�cense No.6_Agy;1J Phone f2d 4d-3702 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ 5h.Ndw Grp, LµT{.� PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well LC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Sr.r 1.yl5/ FOUNDATION AGRICULTURE WELL OTHER wELI PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i. n Industrial ❑ Open Bottom ❑ Manteca Ois. of Well Excavation Dia, of WallCasing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — 0 Public l7 Other ClDelta Depth of Grout Seal Type of Grout C1 Irouation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Wall Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/AOOITION Ll DESTRUCTION G (No Septic system permitted H public sewer is available within 200 feet.) Installation will verve: 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity 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: "1 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 subcontracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componsr tion laws of California." The applicant must call for all requir iniops tions. Complete drawing on reverse Sid r " 02 4 N.rl ?y�9�X11 Signed sf TiTitle: w �" t Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 3 Z Area Ltaul�' C 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 PE /SERVICES A �� 445N SAN JOAQUIN, 'P O BOX 2009 S N, CA 95201 FEE .AMOUNT DUE AMO REMITTED CK CEIV v DATE PERMIT NO. INFO n�e /qQ.'�) CASH//�� /� . ER 134/1xEV.,rm ml�� V•,v-. .� Ntl 31 CT?' C/2-063 EM:1.10