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U APPLICATION FOR PERMIT t J 01 COUNTY PUBLIC HEALTH SERVICES PAYMENT p(SS UN RONMENTAL HEALTH DIVISION RECEIVED CAm!�� i0o 2009, STOCKTON, CA 95201 $ANjOA�OKivtTN' p� (209) 468-3447 NOV 6 1090 G PERMIT RRPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN r(E_INT PUF3LICN�ALTH ,;�RLIC�S (Complete in. Triplicate) NVIRONMENTALHEALTH0IVISION E 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 end Regulations of San Joaquin County Public Health Services. Job Address ..35 55 U/, it awl neer Lanz City Lot Site/Acreage /Oo'fc 100 1 � // Owner's Name Q •t �< 5�n�_ or adless D D /�Jr n S�c/S �iK.af1,1 f� f Phone Contractor Address t'7dl e .4r%fl, 9S PhoneG -D oN TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Mell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well LT. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES QUaColDISPOSAL FLD. PROP. LINE FOUNDATION'_ O AGRICULTURE WELL OTHER WELL'r 50 PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l .e Y ❑ industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation " - -Dia. of Well Casing U Domestic/Private It Gravel Pack ❑ Tracy Type of Casing A/C. Specifications SsA. ya M Public 111 Other ❑ Delta Depth of Grout Seal •+i ,26, Type of Grout Ala 1" /vuraf ❑ Irrigation _Approx. Depth ❑.Eastern Surface Soul Installed by F"'u,.A Ire I Repair Work Done ❑ Type of Pump H.P. State Work Done _ 11� Sealing Material L Depth h b..:l�^-•,0 remje•�! 5=/T` Well Destruction ❑ Wall Diameter _.a_ Depth -1-T -' fie 30 Filler Material i Depth 1//2 -Y T/will TIC WORK: W INSTALLATION D REPAIR/ADDITION Ll DESTRUCTION CJ (No septic system permitted it public "war is available within 200 feet.) " ill serve- Residence — Commercial Other iving its: _ Number of bedroomsf to a depth of 3 feet: Water table depth S ❑ Type/Mfg Capacity No. CompartmentsPENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING E ❑ No. g Length of lines Total length/size FILTER ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PI 11 Depth Sire Number SUMPS LI Distance to nearest: Wolf Foundation Property Line DISP94AL PONOS ❑ j 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 Home owner or licensed agent's signature cenifies 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 subcontracting 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 cast call for requ d ins coons. Complete drawing on reverse side. Signed X ` �`4 Title: 4- me?"I't e i Date: I FOR DEPARTMENT USE ONLY Application Accepted by /Jr f Date L (] Area Pit or Grout Inspection by % Date .4 Z•4 f Final Inspection by Date Additional Command: - f _ Applicant - Return all copies to: . SAN, JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES -' 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED /JCk H RE ED BY DATE PERMIT NO. . EH 13-24(PEI.11.a1 JS�O® /.(Yf7 `//J`4 /�(ii 90 lQ,3p� EH:baa