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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 PERMIT EXPIRES 1 YEAR FROM 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Inh Addrr ss 290.5 Wes f Q of i a m r•h No /1 Dr. Cit, S�OCk7 o" Lot Size/Acreage GhG✓I'Or1 Proa�uc�S Co ,2410 Camino Ranioh Phone Sid S�{29SGb Owner's Name Address CASH RECEIVED BY C Contractor'6Or1S y ` /OrG AA Af, L-WfCtr4ddress ? 9 S% 2 D esti! CA 7, License No. �Phone 7407 ys�� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ 6-(D.7q1603335 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK s*4900't4A SEWER LINES NA DISPOSAL FLO. WA PROP. LINEv • FOUNDATION > 7S' AGRICULTURE WELL NA OTHER WELL 257"' PITS/SUMPS t" - INTENDED USE 81A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom Cl Manteca Dia. of Well Excavation 8 r„. _ Dia. of Well Casing U Domestic/ Private ❑GGrravel Pack n Tracy Type of Casing5%_4D PYL Specifications I'I Public Ir n Delta Depth of Grout Seal 5f'• Type of Grout or 0anA lacoibiik I Irrigation 2S -Approx. Depth I I Eastern Surface Seal Installed by Drills✓• Repair Work Done U Type of Pump NA H. P. N State Work Done _ Well Destruction O Well Diameter N A Selling Material ii Depth PerflavlJ h3eAnirovt;k. arot,c- 11”. -�-T NAr Filler Material i Depth -93 Sand ZDpf• Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I (No se tic syste permitted if public sewer is availaf6l0 within,2OQ feet.) Installation will serve: Residence — Commercial _ Other — Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 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 shall employ persons subject to workman's compensa- tion laws of California." The r;pplic nt (nust call fo r m.7w ionVoeete drawing on reverse side. Sigr d X�.- - � �, i Title: s rT �GD�IJ/S� Date: W 3 FOR DEPARTMENT USE ONLY Applic�tibn Accepted by Date Area 3 S. o/ Pit or Grout Inspection by Additional Comments: Date Final Inspection by Date 4'r_ _ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services /) 445 N San Joaquin, P O Box 2009, Stkn, CA 95201j� EH U -N 111EV, i i n 51 EH 14.20 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE ��- 2523 :7- MX1 6-(D.7q1603335