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• APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PROM DATfi ISSUED (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 San Joaquin County Public Health Services. f� Job Address 393 'ta/If ea.) &`! I` IC/ity.L/� Lot Size/Acreage 3•�a�.�s Owner's N•^• <5/1/14t Trkc4� �. Address �3/ Ala4q" " iv6da 3^3 Phone a�f - 43eoEwaAST c-59 (Al6 (�ry�''��"""""��ractor ��TkYI� �PLO(_L_M��) Address r 1�8LlRG Ch�a(p>''1 License No.�a�� Ire & TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑/ SYSTEM REPAIR ❑ OTHERr❑ Monitoring Well w! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F,LD. � _LL— PROP. LINE 10 Y'� FOUNDATION �_r AGRICULTURE WELL OTHER WELL" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z1f ❑ Industrial ❑ Open Bottam ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing File, Specifications SCA! M Public Q'fi�ther ❑ Delta Depth of Grout Seal 2 30'YO/ Type of Grout4%if47f Ce-*7a1 t. 0 Irngation /Ce Approx. Depth ❑ Eastern Surface Seal Installed by 14-116&P— r ., Repair Work Done ❑ Type of Pump Wonl—p H.P. St to or one Well Dest{uction O Well Diameter Sealing Material L Depth GS 30^46 / •3 G — �i essbref' a7pepth 6C7 r Filler Material i Depths$ TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADOITION ❑ DESTRUCTION Cl (No septic system permitted it 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 31 Water table depth h SEPTIC TANK ❑ Typ i/Mfg acity No. Compartments j PKG. TREATMENT PLT. ❑ - _ _ Method of Disposal i Distance to nearest: Well undation Property Lino LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line \ SEEPAGE PITS I I Depth Si Number SUMPS LI Distance to nearest: ell Foundation Props Line DISPOSAL PONDS ❑ 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 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 o1 CalHornia." C too I in - ontr ting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall a oy \J QCR�o k 's compensa• tion laws of California." LJ The applicant mu call for all re 'red 'nspgctions. Complete drawing on reverse side, p Signed Title: i7/� Date: �U .� !� FOR DEPARTMENT USE ONLY Application Accepted by ` Date 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 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE• AMOUNT DUE AMOUNT RE M IT TEDC::AK,,V I RECEIVED BY l DATE PERMIT NO. EH IIIPEV.11.51 EH .m VV O1 'tJ