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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 RIT_ EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address SIRC / X1 W 14 City s-roeLot Size/Acreage aa Owner's Name `--�4 Cv_lr» Ic"A 'S Address S A MGIPhone ?'Sz ~ -3 yl--c ^� tt Contractor -W SIT Address ? License N0372Mir _Phont✓3 T� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION .< SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK La__4 SEWER LINES DISPOSAL FLD. _ PROP. LINE 04 '4" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� yeDomestic/Private `�Gravel Pack U Tracy Type of Casing 19 11"C Specifications e FI Public C] Other n Delta Depth of Grout Seal "LADa _ Type of Grout_ e + I Irrigation 3 Approx. Depth l I Eastern Surface Seal Installed by OA-r/t ,.- Repair Work Done v Type of Pump _ Sy�� H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth Q�[ TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is f(�+ available within 200 feet) Installation will serve: "Residence, Commercial— 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. ❑ , Method of Disposal ` Distance to nearest: Well Foundation Property Line 4� LEACHING LINE ❑ No. & Length of lines' Total length/size FILTER BED CI Distance to nearest, Well Foundation Property Line SEEPAGE PITS 11 l3epth Size Number SUMPS LI Distance,to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 .. 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 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, l 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 cenify 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 must call for all required insPections. Complete drawing on reverse side. Signed X�� yam,._ _ Title: P--L/-Q f . � Date: R DEPARTME USE ONLY , Application.Accepted by , 6 W Date IIII _ Area Pit or Grout Inspectionby Date a final Inspection by W Date j 7 Additional Comments:o C L4 t Applicant - Return &11 copies to: San Joaquin County blic HealthRYryk: `'� c..ptl �I'C�+.d+:,. j r r v,4 a,,tcor•.a, Services, Environmental Health Permit/Services 4, p.a-4-.% 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERM17'NO. CASH EH sig Inew.1,�„ PN �'3�,/, au f.3�} oo ��11 g 1� q� 4'r. -�, y !.v P