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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 install the work herein described. This application is Stade 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 35'1 Natf7OW T—P �LCity Lot Size/Acreage �� 7- Owner's Name PA'WK D� �?yUGK�G� Address 'f � A142 Phone 1375 �/r w_ CodWAiA_ /�Oj k/. /L/ ��L�t�� License No.6S��77 Phone `�� —6 2-6 Contracto _ .+caress TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHERE:-' jMonitoring Well y5L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.L✓ PROP. LINE , FOUNDATION N,/f� AGRICULTURE WELL � OTHER WELLI1d I PITS/SUMPS �— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation � Dia. of Well Casing N [I Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ A) Specifications i ,,/ I'l Public (-1 Other fl alta Depth of Grout Seal 5:9 Type of GroutLvA'rc�nf Cr I I Irrigation _Approx. Depth astern Surface Seal Installed by �Z.4 Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction O Well Diameter _ Sealing Material & Depth Fa/V77 Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of Irving 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 L'IFF LEACHING LINE Cl No. & Length of lines Total length/size F r' FILTER BED n Distance to nearest: Well Foundation Property Liri �G33 SEEPAGE PITS 11 Depth Size Number SAN SUMPS LI Distance to nearest: Well Foundation Pr gRq ;N X14 `.Jf'd DISPOSAL PONDS ❑ tiv 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 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 applican st 11 for all r uirad inpections. Complete drawing on �avve/rse side. Signed Title: on verse �� Date: �l / FOR DEPARTMENT USE ONLY (/ Application Accepted by ^'" Date �/ G j Area c'/4 t Pit or Grout Inspection b, AWVI- 9_0_ [ Date /aS Final Inspection by Date Additional Comments: 5S6-1 •A Applicant - Return all copies to: an Joaquin County Public Health Services Environmental Health Permit/Services „ J, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. V