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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOC%TON, CA 95201 K,4 .,JorSA (209) 468-3447 010 `(qo—0z5 YEAB PROM DATE ISSUIM (Complete in Triplicate) Application is hereby made to San Joaqui County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address hP Av ! 3— 34o—21 City 5T. MermiLot Size/Acreage Owner's Name Address R?Pam [utb _ _ Phone r., I Contractor r_Address� G $ License No.]5(2-2-(0 6) ._Phone s TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ SerYift-Weii G1 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 4KT ST ( �2lt`fCaS�1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS +tlb INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r n Industrial ❑ open Bottom ❑ Manteca Die, of Well Excavation Ring U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing $peeifiestions M Pubiic (-I Other ❑ Delta Depth of Grout Seal Groot C! Irfioation Approx. Depth d Eastern Surface Saul lnslatled by �,5r_ Repair Work Done 0 Type of Pump H.P. State Work Dona 10l«k-(-•'hAC kn4Q-�'� �P rtl�r Well Destruction O Welt Diameter Sealing Material 4 Depth _�rh•w. 0,,coLkN76R6> Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.l 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. Compantmants PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED (_) Distance to nearest: Well Foundation Property Line s SEEPAGE PITS 11 Depth Sita Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, sncl� 1 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 sub-contracting signature certifies the following: "I certify that in the rformance of the worts for which this erma is issued, I shalt employ persons subject to wo kman'a compensa• tion laws of California." , The applicant st c or all cti ns. Complete drawing onv r si / Signs d Title: Date: I FO DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: F26Po v•i �• " " u Applicant •• Return all copies to: S JOAQUIN COUN PUBLIC HEALTH SERVICES ; ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE: PERMIT'NO. . EH l3.74 IfrEV.I/N 51 , L 3 •� i EH.�•m v