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.t APPLICATION FOR PERMIT AQUIN COUNTY PUBLIC HEALTH SERVICES / y QJJ ENVIRONMENTAL HEALTH DIVISION v ' P O BOX 2009, STOCKMN, CA 95201 ,SUN X991 (209) 468-3447 2a-/o08—z/7 R c_4_ ss (Complete in Triplicate) t_;;•,1RONMEMAl Application is hereM,t�f,��JaRV"quin County for a permit to construct and/or install the vork herein described. This application is made in coupliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 20d0 Wo f*LrP1rrX_ si�21/r _ � City� 1'�l� Lot Siiz-er/Acreage Owner's llama, AW L Address ZzZ it W40{a/L 11W , 61g Phone Contract -4" I Address?ZZ5� LC. fnX_/ Je 5]% License No. 67ZZ69? Phone rg— TYPE Of WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 e PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHERX Man'tor-Ing 'Jail- Cal- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 37-6 FOUNDATION AGRICULTURE WELL OTHER WELL /if J� INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS >b f*Z®r n Industrial D Open Bottom D Manteca Dia. of Well Excavation U Domestic/Private Cl Gravel Pack C1 Tracy Type of Casing _6pecffetsatfotts L Public 1.1 Other D Delta Depth of Grout Seal J4y@.ef-6Mut CI Irrigation �.Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION 0 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal X Distance to nearest: Well Foundation Property Line LEACHING UNE D No. & Length of lines Total length/size FILTER BED I::I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Silo Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1n 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 t\ 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 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 laws of California." The applicant mu cail for all Lared inspections. Complete drawing on reverse side. Signed XL _. Title: 5�jdLaeSlS Date: _ 6—!AT-'q l _ FO DEPARTMENT USE ONLY Application Accepted by Date 6~ Area cC�� 67 Pit or Grout Inspection by Date Final Inspectionby, b Date v�C -r�r Additional Comments: 49- c7 ' r ��v _. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2409, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE /tPERMP'NO.AA . EH 1 .24(REV.)� 51 q M1 �.C]9 EH;x.26 f i r I_ L �y l V, a%