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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 VAKA P O BOX 2009, STOCSTON, CA 95201 Avt6' PERMIT EXPIRES I Y FR M DATE ISSUED 3c), uJESTSrt (Complete in Triplicate) '35-i-f2-0 b Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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 5c �qr � N16 � Job Address J Y� City CAW Lot Size/Acreage Owner's Name AZhvt4yJqtl* A)` Address ` P on ifbb 1149 /49 Contractor Address ��'�t-r License Na. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll PUMP INSTALLATION E) SYSTEM REPAIR ❑ OTHER>k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -Pft81".-t file ' t FOUNDATION AGRICULTURE WELL OTHER WELL11=e1el1l P-g b�oY �jS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IVIJ i-CL K!! Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9 r Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ � +s 1'1 Public 1-1 Other ❑ Delta Depth of Grout Seal c-^ TVMr*kGgout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by 6AA, 460�hg Repair Work Done 0 Type of Pump H.P. State Work Done W41 W � Well Destruction ❑ Well Diameter Sealing Material i Depth `\1I1 �k 14 Depth Filler Material i Depth j Q TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION i 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units; Number of bedrooms Character of sola to a depth of 3 feet: Water table depth r vvvyttr SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT.❑ 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 Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby conify 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: "1 certify that in the performance of the work for which this permit is issued, I shelf not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 fofnia." The aicant at Cali 11 of rV8qu ,1.1tions. Complete drawing onreverse side. SignedTitle: / Date: I 9 FOR DEP T USE ONLY l Application Accepted by Date A a gD— ` Pit or Grout Inspection t Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDK H RECEIVED BY DATE PERMIT NO. INFO a T • EN 1344 111EY.��n of EN 14.78 a C� 2L- ____JZ v