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� l APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH" SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 '� N (Complete is 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. .fob Address ?/ �' /�� 5�� J City Z4"A400_ Lot size/Acreage � 3 '� 2G29a S. Glrn.:o.n � C/ Phone 8z 3 " Owner's Name a G Address Contractor Address Zg Ste• /fit r License No. S�ZZrog Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION NCPUt of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D T�FT�Fi R C] Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK > 'SEW;ER LINES _> 9)1 DISPOSAL FLO,> IF 4 PROP. UNE �/Z 1 01 FOUNDATION � AGRICULTURE WELL--2 OTHER 'WELL PITSISUMPS 2�O INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1P L-t2E G 20CA to Industrial O openBottom ❑ Manteca II Dia. of Well Excavation _'1D _ Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing fr 190E 15"1140 Specifications M Public 1-11 Other © Delta Depth of Grout Seal Type of Grout Irnpation _Approx. Depth ❑ Eastern Surface Seal Installed by # " Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction Well Diameter y!!--- Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION C1 DESTRUCTION-CJ iNo septic system permitted if public-sewer is available within 200 feet.) Installation will serve: Residence Commercial Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg a Capacity No. Compartments PKG. TREATMENT PLT.C1fj ; ,. m Method o1 Oispo al. Distance to nearest: W`all I Foundation Property Line 4 it LEACHING LINE ❑ No. 6 Length of lines j Total lengthlsize FILTER BED n Distance to nearest: Well ~ Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: We11 Foundation Property 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 ticensad 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 t o nis", The epplic nt mu call for all required in ction . Complete drawing on reverse side. Signed Title: /" r. oats: z y Z C^'• - '�PA-RTMENT USE ONLY 5.Application Accepted by r l '"� _ _ 5 �_ 4 Area --- N1� Dace _ � . 5'Z Pit or Grout Inspection by Date �+ 1✓ Z Final Inspection by w'� Tom_ Date Additional Comments MDn.d�'iyl5 �YJfr� �►WtA/ ' f•1� 'f Q iVL`1 �� y ��j Q -•-- — 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 65201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEEVEO BY DATE PERM17"NO. INFO CASH s�rrrFv.r,�„ (Oo.od &© -`�� 5:2--1