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h i li APPLI CATI ONS FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION P C BOX 2009, STOCKTON, CA- 95201 _b (209) 468-3447 i R (Complete iurTriplicate) Application is hereby made to San Joaquin CO=ty 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. Job Address s 4M �A) � City 7 ELC Lot Size/Acreage Owner's Name-�1IE2QA RA-1 Gi'A Address T:Q. RO'X 507015 a ��7A8 3 - 77r' 12,.__ Phone i Contract"*I&MIJM EXA-0R _ Address,1625. iEMYR16. License ho.,?)2.2./oa Phone --E-7/ 'Z TYPE OF WELL/PUMP: NEW WELL CT WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service:iWell. ❑ PUMP INSTALLATION ❑ SYST'E/M REPAIR C1 OTHER 3K Monitoring well, CX DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _1��. DISPOSAL FLO.At'1A PROP. LINEOQ r. FOUNDATION Sb AGRICULTURE WELL OTHER WELL _ PITS/SUMPS 116�a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yDP-oPLwG Ll Industrial 0 Open Bottom 0 Manteca' Dia. of Weil Excavion ----Z�_ Dia, of Well Casing : JK.Domestic/Private 0 Gravel_Pack racy ii Type of Casing_�1�1�4 Specifications C3 Public XDther 0 Delta ,7 Depth of Grout Seal Type of Grout CI Irri ation Approx. Depth ❑ Esuern Sura' ce Seal installed by Repair Work Done 0 Type of Pump H.-P. 7,Stats Work Done .. 4 Well Destruction O Well Diameter Sealing Material It Depth 4 Depth Filler Material i Depth "~ ' � I TYPE OF SEPTIC WORK: NEW'INSTALLATION 0 REPAIR/ADDITION Cls DESTRUCTION U INo septic system permitted if public sewer is C E available within 200 feet.l � Installation will serve: Residence — Commercial_,.._ Other - Number of living units: Number of bedrooms Character of soil to a depth of 3 lest: SEPTIC TANK. Water table depth O Type/Mfg Y Capacity �1 ' PKG. TREATMENT PLT.O nadat . Distance to nearest: Well '! Foundation PropenRErSELVED ,., :I 11 LEACHING LINE ❑ No. S Length of lines N 9 Total length/size FILTER BED C) Distance to nearest: Weil '' f=oundation Pro�FR P �r� SEEPAGE PITS 11 Depth Sia '' Num at SUMPS LI Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ i� ] I hereby cenify that i have prepared this application and that Ilia work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County i 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,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Conirsctor's hiring or sub-contracting signature cenifles the following:"l cenify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman'rcompensa- tion taws of California." The applican[ mLot caT t all required inspections. Complete drawing on reverse side. Signed Title: ✓"+ Date: ' � Z FOR DEPARTMENT USE ONLY Applicalion Accepted by Date 3 -�2- Area 3� Pit or Grout Inspection by `" D Final inspection by Date P Additional Comments: " _ Applicant - Retttrn.all copies to: SAH JOAgUIN COUNTY PUBLIC HEALTH SERVICES ENVIROFYENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O box 2009, STOCKTON, CA 65201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE Pt RMi7'NO. i1 INFO CASH i; t„ ti•7e 111EV.r i w as� 89`� '. C rj� Ii