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APPLICATION FOR PERMIT 1 e4 P, r t ANN. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 952013f; (209) 468-3447 p, ;, 1990 <ijl�klrl.`•.L ,, �� R I (Complete in Triplicate) Application els hereby made.to San Joaquin County for a permit to construct and/or install .the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address i,97 3XX S 1 a City—i-pMalLot Size/Acreage 1 r 2 A Owner's Name GLEAWA S09II, Address c Phone i r!�� rte. Conlraclor �T4r=`Address S cense tVo. Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR Cj ! OTHER 0 Monitoring'Well C7 DISTANCE TO-NEAREST:+SEPTICrTANK-.1 � - - - SEW-ER:.LINES;� ' t:rv-=- _Dl5P-0SAL,=FLAAIQ `L-,PROP,rLiNE-�:��-;�-,::, FOUNDATION " AGRICULTURE WELL ~-' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C71 Industrial ❑Open.Bottom =-L] Manteca Dia7cif-Well Excavation Dia. of Well Casing \-A!�.Domestic/Private. IZJL�ravel'Pack. Bracy Type of CasingII! floq, b90 Specifications M Public -0 Other ,, # '❑ Delta Depth of Grout Seal / Ir Type of Grout CJ Irrigation /A Approx. Depth 'C) Eaitern '� � Surface Said Installed by Repair WorkDone LJ Type of Pump H.P. State Work Done_ Well Destruction- —0---Well-Diimetelf Sealing Material i Depth Depth # .► Filler Material & Depth TYPE OF SEPTIC WORK: .NEWINSTALLATION D REPAIR/ADDITION Ll DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence^ Commercial____, Other -f Number of.living units: Numberlof bedrooms - r,,J Character of wil to a depth or 3 feet: # Water table depth SEPTIC TANK.. O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines `.Total length/size FILTER BED C1 Distance to nearest: Well Foundation J Property Line I jT1 SEEPAGE PITS 11 Depth Size Number SUMPS r - ,•-,Ll—Distance to nearest;* Well- � �-=�-P►aperty 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 Some 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 c6rnpensation Iaws of California." Contractor's hiring or sub-contracting signature certifies the following: "I c ify 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 app)' t u 11 f alt re ed inspections, Complete drawing on me side Signed Title: Date:! R DEPARTMENT USE LY / Application Accepted by Date Area ` Pit or Grout Inspection by Date Final Inspection by Date i_�Ys�Na t y �, y' Ger Additional Comments r�v��,. � ��l¢,�; i2y�rzg' Applicant - Return all cope to- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 495 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 r FEF INFO AMOUNT DUE" AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT NO.- . EM 13-24 IPEV,s