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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A ENVIRONMENTAL HEALTH DIVISION �ft �rr ly P O BOX 2009, STOCKTON, CA 95201 Cje1 VeD (209) 468-3447 NAR 2 : ot)RNUTC L10�PTRHIT EXPIRES YEAR PATE SA" pmete iaTrp �1OMEHNry JrAL SvI� Application in hereby made,to San Joaquin County for a permit to construct and/or install the vork herein descr e't1DI application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Joaquin County Public }health Services. A pIL) 2-21-IM-10I2-21-IM-10Job Address _ , /f40ic'sa-.r RZ_V 1) ___— __ City )V7gC& I+ot Size/Acreege � 1rS/�C _ Owner's Name Vd4U Ljj&rSrjEVr 00- Address P0- lex S7e74-56 c 25,-?&, Phone Contractor Address 7 ZS Myr�`/eSf S iW_kn6 r License No.15/224P Phone a- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES j 2-S ' DISPOSAL FLD. PROP. LINE IS' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1530 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr f_7 Industrial ❑ Open Bottom X Manteca Dia, of Well Excavation �(� _ Dia, of Well Casing Alf Domestic/Private C1 , Grave! Pack Tracy Type of Casing_ yc Specifications.SCJ2. dri M Public I'l Other D Delta Depth of Grout Seal StJ0 44 E-- -- Type of Grout.LQs°ft2 eAr Ca Irrivation 5tO_Approx. Depth 0 Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material fr Depth Y- '-TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 lost.) Installation will serve: Residence_ Commercial— Other Z Number of living units: Number of bedrooms Character of*oil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 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: Wait Foundation Property tine DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and M 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 lawn 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 m st c4V for all eq "r d ins ction . Complete drawing on (averse side. II�� Signed Ti Is: .641 &47,+,t17 Date: H41gg Z-2,- JY2/ FOR DEPARTMENT USE ONLY Application Accepted by / C Date ( Area 44 " Pit or Grout Inspection by '" ate !/VFinal Inspection Date Additional Comments: -54) Applicant - Return all copies to: SAN JOAQUIN COUNTY aBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE A�M•,O[V)NTTf REMITTED CK If RECEIVED BY DATE PERMI7'NO, EM 17.21 iREV, i n 71 �t1 ._.�-" C.p• ]( ('�� f'r ZL/ ! ��t y 1 c� f f 776