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• APPLICATION FOR PERMIT 90all ttOUNTY PUBLIC HEALTH SERVICES TAL HEALTH DIVISION 445 N SAN IAQUIN, PHONE (209)468-3420 DEC 14 14A0X 2009, STOCKTON , CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTALIpldplete in Triplicate) PERMIT/SERVIC 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 comiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r a>ileci Lot Size/Acreage - eS)*-23--3/11 Pho Owner's Name ee.-----...kiti-- 62/J -Skr,fyeAddress (SG'177-7‘) Ze )07I , A 24' i.C/ck-.P1-7) 41626/70 Contract , Ire' -1._ .Gi Address (ft License No. Phone j TYPE OF OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT rl DESTRUCTION 0 f Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 3)4onitoring Wel.15,4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PRb LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS if CI Industrial 0 Open Bottom Manteca Dia. of Well Excavation P" Dia. of 'Well Casing ,D511 LI Domesti /Private DirGravel Pack Li Tracy Type of Casing PVC Specifications •02c-,/1"1.- .,.., t 1'1 Public 0 Other 11 Delta Depth of Grout Seal "" 2- (../ Type of Grout ./7•1Gi'r i I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work Done -, .• Well Destruction 0 Well Diameter e--' Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi cc Commercial Other ___ Number of living unit Number of bedrooms Character of so a depth of 3 feet: Water table depth SEPTIC TA 0 Type/Mfg Capacity No. Compartments PKG. T ATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line -- LEACHING LIN 0 No. & Length of lines Total length/size FILTER 8 0 Distance to nearest: Well Foundation Property Line .., SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISP AL PONDS 0 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 Horne 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. 4/2.- el Z-ney=' The applican ust tall for #1 requ.i,d insTs. Complete drawing on rev Signed X Title - Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Pit Of Grout Inspection by Additional Comments: Area 27/771— IkOoc)c) Date Final Inspection by 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 EH 1124 IFIEV. 1 5/ Eli 14.26 FEE INFO AMOUNT DUE AMOUNT REMITTED CraeC" CASH RECEIVED BY DATE PERMIT NO. (4S i /07/9Y 00C°J-0