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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 O BOX 2009, STOCKTON, CA 95201 OFFS ITE PERMIT EXP I RES 1 YEAR FRPM D TE vrl i,`L (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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. (4,2*ew pFDAwes RhbA ") Job Address 3 a+Q Vt ` 7s.-J (T1(rlr City ` d��'" L°t Size/Acreage A ssocwro W i-rN Afmasy coourJr4 rnwae caMpkvy ;;owneName 7�re �7'sso s _ Aaaress'IVEsrr4AT704 f}T /S0 W. S/NcL�lre._161 IX if-Ttwictt Phone w 3 XIt/4t, F. n, box 8 053 31 CgoS� Contracts WEZ_L JWfL- . " Address_BIRtc�e(sFIEcD�C#4 y M0__�S3?License No. .'S77%33� Phone 39 ^8912 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well A 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 —r4154-4E SW R4'2 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s/rs N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ STEEL_ Specifications I') Public IX other MOAIM- fl Delta Depth of Grout Seal is L' Type of Grout I i Irrigation —Approx. Depth I I Eastern Surface Seal Installod by_ SPI!6 L M/r mc- W CL Repair Work Done 0 Type of Pump ..fdlsll�FJr!SIbCE H.P. y2_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soar to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a 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 workmen's compensation laws of California." Contractor's(tiring or subcontracting 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 applicant at ca o 1 aired inspections. Complete drawing on reverse side. Signed Title: _- FC f1� G 'Gr3�./Ji Date: =I f D .E FOR DEPARTMENT USE ONLY Application Accepted by Detre J j Area r Pit or Grout Inspection by �w Date rb Final Inspection by 0 a t 9 q// Additional Comments: W- Tyr Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services S O r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY TDATE PERMIT'No. ♦ EN1 3.281R1N.1/IIEk fH 1 .26 two, v