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w � APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES DFC 07 3990 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 =IT UPIRES 1 XEAR_ PROM DATE ISSUED ` (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. p �j Job Address I D l a/ aw�r rlgC.�d�/d�i,,,4Ra, City IIV C- - Lot Size/Acreage Owner's Name 2�5'71&)` Cff 9-7/?'4/ Address 2 30d Gor �rl' r a `--'f/G[e- f Phon/, 183 4 �t(A!a a1 Sj S><e 7 Contractor EEG L Address o evi lle License No. 410 Phon TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT !7 DESTRUCTION V Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well L1 DISTANCE TO REST: SEPTIC TANK d'oNe- SEWER LINES nlaOk/-e- DISPOSAL FLD.W11,11% PROP. LINE +Q-9- FOUNDATION ALZ__�e AGRICULTURE WELL Q-OTHER WELL PITS/SUMPS AJ le- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Gout Ml IrnOation Approx, Depth ❑ Eastern Surface Seal Installed by ~ Repair Work Done 0 Type of Pump N.P. Stats Work Qon* Well Destruction ❑ Well Diameter Sealing Material i Depth or- ca + Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L3 REPAIRIADDITION 17 DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other { n Number of living units: Number of bedrooms U y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well 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 licensed agent's signature certifies the following: "I comity 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 earlifios the following: "I canny 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 must call for all required inspections, Complete drawing on reverse side. Signed Title: Date: 7- Z' qa J��_ FOR DEPARTMENT USE ONLY / Application Accepted by f / Date ��"��a Area� 2 Pit or Grout Inspection by Date Final Inspection by Date !Z 2 Q Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. INFO . EH 13,241REV,I/>tsl � /' If/ �! �,C�7_! • �•�j��/ EH 14.20 p