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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION P 0 BOX2009, STOCKTON, .CA 95201 (209) 468-3447 PERMIT E%PIRHS 1 YEAR ?RQ9 RATE 115a= (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in coa>pliance with Sate Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address :26(2 G SQ 'r'`�n1 City/Y/ /v Lot Size/Acreage 2E,,4 EST�ArE OF- 5 -06 Owner's Name C/J.S,427_�F Address ��,, D YALE ST 24131 9.4l32 Phone 05T"E R 8 F-g 4. Irr 7-5-73 Ql&*00- ) Contractor a Address , �" � License No. rt•76 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION K Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 ,�/OTT,HER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK /VA4 SEWER LINES _s'_�._. DISPOSAL FLD _ PROP, LINE L42 FOUNDATION s�0■ AGRICULTURE WELL &&___ OTHER WELL.._. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom $Z Manteca Dia. of Well Excavation 4" Dia, of Well Casing {/f Domestic/Private Q Gravel Pack 0 Tracy Type of Casing 2))40 _PG` Specifications M Public 11 Other O Delta Depth of Grout Seal 51JR,04CB Type of Grout M IrriUstion _,Approx. Depth ❑ Eastern Surface Saul Installed by rZ4CTd/7- Repair Work Done U Type of Pump H,P. State Work Done _. Well Destruction 5( Well Diameter Sealing Material A Depth Depth Filler idatarial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G JNo septic system permitted if public sawet is available within 200 leat,l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: W r Iit SEPTIC TANK 0 Type/Mfg Capacity N PKG. TREATMENT PLT. 0 M Distance to nearest: Well Foundation - P(opefiv Lina V93 LEACHING LINE 0 No. b Length of lines Total length/ IN FILTER BED n Distance to nearest: Well Foundation Property LKWIMER SEEPAGE PITS 11 Depth Sire Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this appfication 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 of 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 California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensa- tion laves of California." The applican call sl[r u'a ins coons. Complete drawing on averse:ids, Signed Title: Date: A,4aV z?/iiU FOR DEPARTMENT USE ONLY �t Application A cepted by Date 17( r/All Area V Pit or Grout Inspection by. Date Final Inspection by Date ' Additional Comments: Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 446 N SAH JOAQUIN, p O BOX 2008, STOCKTON, CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH `-RECEIVED 8Y DATE PERMITNOO.. Et3-24 11ICV.rrssr V IZ ' '/ EH :/•2e