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MMMW APPLICATION FOR PBRMIT SR�� —�,/� SAN JOAQUIN COUNTY PUBLIC HEAL'T'H SEFAV ENVIRONMENTAL HEALTH DIVISI04 P 0 BOX 2009, STOCKTON, CA 95201 —� ( 209) 468— 3420 FAC # PERMIT EXPIRES 1 YEAR FROM DATEIIEMElk (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein eacribed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulat}one of San Joaquin County Public Health Services. Ct/V C/rti Ty- 4h� /✓'r ),_� F �, _,/A.- Joh Address 8�_ L, MAIQ_S_f _ _ _ City S70CZT-OAJ Lot Size/Acreage }i N:, rc .yrs= Owner's NameAwarLJ Nvf)ur<ir Address Ro•t30X q23 2,xgTt7/J Phone 940- 3011-8 Contractor hikbc// &I , Address e4.130X 2231 j2AA)C A CarraoJA 9574/ License No.G 726 / 7 Phone/)2 _ 9S.S9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER K Monitoring Well DISTANCE TO NEAREST; SEPTIC TANK 131SEWER LINES_ DISPOSAL FLD.A/Z4_ PROP. LINE FOUNDATION AL AGRICULTURE WELL/_t/Z4__ OTHER WELL, /V PITS/SUMPS YZ4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavalion _ 5"' Dia. of Well Casing Af 114 & Domestic/ Private .. Cl Gravel Pack O Tracy Type of Casing_ .S/oNE Specifications ` ❑ Public Other ❑ Delta Depth of Grout Seal 5_0¢F,4GE Type of Grout CCx+,e^/f M IrnOation 4_Q- App(ox. Depth ❑ Eastern Surface Seal Installed by. CoA-272AC.Torz Repair Work Done U Type of Pump H.P. . State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material i Depth - Depth Filler Material I Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial — Other . gR ., Number of living units: Number of bedrooms J "'� 4 Character of soil to a depth of 3 feet: ` _ WgFeh tb10`'depih SEPTIC TANK ❑ Type/Mfg Capacity__ l`JA..PCRmp'srTJrenlrr�_ PKG. TREATMENT PLT, 0 ;, Ma hpOff of Disposal r/a V �i i Distance to nearest: Well C, l Y Foundation P d `�'ES f•^�1�I��M'f��' i� ' LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire _. _ Number SUMPS U Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ rV `1 I hereby Certify that I have prepared this application and that the work will be dune 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 applicant mu call fpr all required inspections. Complete drawing on reverse side. ��` Signed v"'Title:�ra v� Date: `��/"— FOR DEPARTMENT USE ONLY v^ Application Accepted by Date Area 4 o Pit or Grout Inspection by Date Final Inspection by Date MA -A WAMAW� I I e / Applicant - Return all copies to: SAN J&IrUIN COUNTY PUBLIC HEALTH SERVSCES ENVIRONMENTAL HEALTH DIVISION PERU IT/SERVICESS�1 4 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 9520 EH 17.24 IREV. i/A 5i EH '41.26 FEE INFO AMOUNT DUE AMOUNT REMITTED K�'FI RECEIVED BY DATE P T -t y- 501