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A'PLICATION FOR PERMIT d l.i i. SAN JC bWjCOUNTY PUBLIC HEALTH St ICES ENVI$ONYENTAL HEALTH DIVISION 445 N SAN: 'JOAQUIN, PHONE (209)468-3420 P 0 BO%; 2009, STOCKTON, CA 95201 t'j'�k� PERMIT EBP.IRF YEAR FROM D E S (Comp''lete in Triplicate) Application is hereby made to Ban Joaquin Countjr;Tor a permit to construct and/or install the work herein described. This application is made in cowllance vith San Joaquin.County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ' - t L q r F l l N Lot Size ere ��r O 3 :I Job Address 4JH � Hal G City 1 'J � _. Q rL Owner's Name �DlM1Q �Qfi101/G 0 � ddress �•Ude' �1' 7- •�TbN 9 Sz.O Phone xn .Z Contractor S��/SLJsp( l�Wr5_Address(11P40,80x ,jG � License No. �826�6 Phone 7�r' s TYPE OF WELL/PUMP: NEW WELL ❑ ;' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well '❑ I PUMP INSTALLATION ❑ ':' SYSTEM REPAIR ❑ OTHER : Monitoring Wel.11011, DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLU.] PROP. LINt; tet` /y I FOUNDATION �' ;-'"IiAGRII,CULTURE WELL`S OTHER WELL PITS/SUMPS ^ I! t O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Pia. of Well Excavation _ 10;041Me,S Dia. of Well Casing 2; I- ac 1 DomesticiPrivate ❑ Gravel Pk ❑ Tracy Type of CasingL FIvSpecifications - I i I') Public n Other f'] Delta Depth of Grout Seal y ir+af" Type of GroutNm s- I I I Irrigation _._Approx. Depth 1 i Eastern Surface Seat Installed by -��'-i FSawC� -- Repair Work Done U Type of Pump `"` H.P. State Work Done _ ' Wall Destruction ❑ Well Diameter .'' la :tiag Ifr►terial t Depth ' Depth ::Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I-1 REP.AIRYADDITION I I ,DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) installation will serve: Residence— Commercial°"! Other Number of living units: Number of bedrooms. Y L t :It. ' Character of son to a depth or 3 feat: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ I Method of Disposal '! Distance to nearest: Weil" Foundation Property Line LEACHING LINE 0 No. 8 Length of lines C' :<, Total length/size FILTER BED ❑ Distanca to nearest: Well. Foundation Property Line SEEPAGE PITS 11 Depth Silo, I Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that ttro work will be done in accordance with San Joaquin county ordinances, state laws,;and rules and repulatiorta of the San Joaquin County 'j1,11 Home owner or licensed agent's signature cenilos the foliowin0 "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 became subjeci to workman's compensation Lows of California." Contractor's hiring or sub-contracting signature cortifiaa the following: -I certify that in the performance o}.the work for which this permit is issued,r shall employ persona subject to workman's compensa- tion laws of Califorrtls." C The applicant r ��Complete dr'swing on reverse side. f / 1 Spread _ Title: _.� i'a.*c ✓!a✓/ Date: ' 3a Ir' 1 1 FOR VEPARTMENT USE ONLY 1/IIII,YJ R..xn�f/ v, .v Application Adapted by Date_7 Area r Pit or Grout Inspection by �Date1 Final Inspection by- Date UES WAS Addnionar Comments, ....., .... - - ,;, Applicant - Return all copies to: Sea:Joaquia County Public Health Services Environmental Health Permit/Services 445 NJiSan {Joaquin, P O Box 2009, Stkn, CA 95201 �sgli ri ;F ' FEEAMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO .fl I GASH . E+I 2,17195� DoSz j