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APPLICATION FOR PEP-MIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009 , STOCKTON, CA 95201 (209) 468- 3420 PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Se.a Joaquin County for a persalt to construct and/or install the work herein described. This applicstioo is made in eo»italle.nee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sun JoaQuim County Public Health Se Ar �vicers. / Joo Address 2_021 W. 41) Acx4lr )A-7-04J L-3L•u11 CityLot Site/Acrea.ge t5A•f /� L tom-•O �x ��,04�:% / Ownar's Name�l lfCa( 1J_1 (_PV✓l m+_re, Address 2I ueK-1 df,C!} 'Z7lZ Phone(&X- Conuactor � f'1 I c Address U J t ' License No. yif�q 7�z� Pno TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT CI OESTRUCTION Out or Service veli 0 PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER 0 Monitoring Well STANCE TO NEAREST: SEPTIC TANK _.� SEWER LINES ZSR DISPOSAL FLD JI�f PROP. LINE /GLl i FOUNDATION �S AGRICULTURE WELL ALZ OTHER WELL_A�0_ PITS/SUMPS 14Z4 INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS Indusirial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing �! Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Tl/ Specifications-716 C Puolic I:1 Other O Delta Depth of Grout Seal e.__ Type of Grout r ti lmuirl.on _.Approx. Depth O Eastorn Surfice Seal Instanud oy..��Z A-C70Iz- Iepair work Done U Type of Pump H.P. . State WD Nall Destruction Well Diameter Sealing Ysterlal i Depth _ L.� orkon ti�-,i ~'+tr Depth Piller 1Materlal i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/AOOITION 0 DESTRUCTION 0 (No septic system permitted it public sower is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other .Number of living units: Number of bedrooms Character of toil to a depth of ] feet: __Water Idols booth • i SEPTIC TANK ❑ Type/Mfg Capacity_—_..—_ No. Compertn•,ants PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Lint LEACHING LINE O No. & Length of lines _ Total longth/size FILTER BED n Distance to nearest: Well Foundation Property Lino SEEPAGE PITS 11 Depth Sire Number SUMPS L:1 Otitance to nearest: Well Foundation Property Line DISPOSAL PONOS O I neteov cenify that I have prepared this application and that the work will be done in accorbance with San Joaquin county ordinances, state laws. ano rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cenify that in the purlormunce of tho work lot which this permit is issueb. I shall not employ any parson in such manner as to become subject to workman's compensation laws of Calilornie." Contractor's hiring or sub•contrbcting signature certifies the following: "I certify that in tho performance of the work for which this pormit is issued. I shall employ persons subject to workman's compensa- tion Isws of Celitornls." The applicant u 1 to requir d inspections. Complete drawing on reverse side. SignedTitle: Date: FOR DEPARTMENT USE ONLY /y�• l q lx � Area Application opted by Oate Pit or Grout Impaction by Date G� Final Impaction by —` Lt-t Data Additional Comrn4nts: Applic"t - Return all copies toe SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES )�� ENVIRONMENTAL HEALTH DIVISION PERMIT/SEHVICES 445 N SAN JOAQUIN. P O BOX 2009, STOCKTON. CA 05201 X If FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEO By GATE PERMIT NO.