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APPLICATION FOR PERMIT %.0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ►. ,' y" :'. y PE1tMIT EXPIRES I YEAR FROMTE ISSUED (Complete in Triplicate) - - Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cowliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3 7 ?8 /�A_Gy Baole-v,-rd City g6-L Lot Size/Acreage Owner's Name u N►CC+;. Co r pOr0- yn Address 2 2— Croce 54-ni— lac+y S-f woo Phonet toj Z77-235y San Ramon,LA 9Y+?i3 17r C.;21 Aa..d 4 V/�✓.�l ti..•d Contractor Z.4. rte -Was-�ern Co. Address C os6 s (�.,s�.,1a6A License No.S�ool CS•7 Phon 9/L 647-MAS TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION VOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (See Ali -`-,eA t7'�*°�^►, * Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domostic/Private Cl Gravel Pack7 n Tracy Type of Casing Specifications I'} Pub11t In Other n Delta Depth of Grout Seal Type of Grout 1 1 Ir,igation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. Stats Work Done_ eft Destruction Well Diameter 2 tech Sealing Material i Depth tJt..+4.er.. +. Depth 20 gc--+ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION i I DESTRUCTION I t (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residents_ Commercial_ Other Number of living units: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments 0 PKG. TREATMENT PLT.❑ Method of Disposal ya Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of tines Total length/size FILTER BED CI Distance to newest: Well Foundation Property Lino SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to newest: Well Foundation Property Lino DISPOSAL PONDS ❑ 1 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 Homs 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 Csfiforntia.-Contractor's hiring or subcontracting signature certifies rho following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion lawn of California. The applicant must call for all required -iin-sp�*.etions. Complete drawing on reverse side. CSec-A*--k J St+e- pjo-^, Signed x Jr s�..rJ Title: 0.6 H drtF.�4rl�- M.*el�0- _ Date: /1 lJ19Z �� Lvr�•+kti�� FOR DEPARTMENT USE ONLY Application Accepted by Data 11Area Pit or Grout Inspection by Date /t ZdL Final Inspection by Date Additional Comments: !%K"�' 0 3 41 Applicant - Return all copies San Joaqui County Public Health Services Environmental Health Permit/Servicee ,_f( 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 v •� IF EE 0 AMOUNT DUE AMOUNT REMITTED CASH CK /RECEIVED OY DATE PERMIT'NO. . EM/124(REV.1185) 60, 17�� 16YD NL4 l-' I s2 f� D/ EM 11�