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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CL ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 DEC 2 (209) 468-344? 1g�Q t PERMIT EXP1990 I XZ"in r OM DAT) ISSUEI} ENVIkoNMEN-rAL(Comple PEW11T/sERVjC. Application is hereby tnade.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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f- " 1� - Job Address 21rlav D"VV City 5;Mkf�7 Lot Size/Acreage Owner's Name S Se�v1(a _.._._ Address _ Zq4 f Iy2yi1 b� - _ _ Phone( ` SSG'Z + — I r Contractor a X Iv�.G Address � 5 : .M rff6 License No, s�g . Phor(e 70) W_ 012- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl Mon toring WellPUMP INSTALLATION r� SYSTEM REPAIR C1 OTHER 50 Q r ?3!L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 8�4 .l�lJ SO DISPOSAL FLO. 75s PROP. LINE '� FOUNDATION F d0 r AGRICULTURE WELL y2_26- r OTHER WELL >100 f PITS/SUMPS >/00 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (9 Domestic/Private ❑ Gravel Pack:{ E7 Tracy Type of Casing Specifications Cl Public f+?7 Other bbFinJcy ❑ Delta Depth of Grout Seal Type of Grout i � G Irrigation L..Approx, laepth p Eastern Surface Seal Installed by Repair Work Done D Type of Pump f H.P. State Work Done _ N Welt Destruction ❑ Well Diameter I Sealing Material & Depth Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEW INSTALLATION L] REPAIR/ADDITION 0 DESTRUCTION FJ iNo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence^ +Commercial_ Other Number of living units: Numberofbedrooms Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK. ❑. Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Welt Foundation Property Line �. i� LEACHING LINE C1 No. & Length of lines Total length/size ! FILTER BED n Distance to nearest; Well Foundation Property Line `1 SEEPAGE PITS IJ Depth Size Number SUMPS L1 Distance to'nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 Sen 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, t 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: "1 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." I The applicant must �call for all required inspections. Complete drawing on reverse side..F � : Signed X i , Title: � rn f ma_. /r-, _ Date: I�21 L10 J� FO ARTM SE ONLY ��SztiL�v� Application Accepted by DateA.A. 3� Pit or Grout Inspection by l Date Final Inspection by Datey//J .� Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED BY DATE PERMIT'N0. . EH 13,24 IREV.I II% t�� 3� ~! / 71'17- Y EH;4.2