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APPLICATION FOR PERMIT U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIR$S 1 YEAR FROM DATE ISSUED � • (Complete in Triplicate) Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein deacribed. This application in made In coopliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ff '' 1 e L Job Address 20105 W• 2e--1A1t aw11✓I ftp 1+by t ve City 5+-0r L-bI0Lot Sizee//A_creage fie/ Owner's Name CGi' evrorP•OL��G'J'(eAddress � hons -a 7z- Contractor "` /�`r Address �� Lzt✓,�#*r L11 License No. ?YI?3f0 Phone -'6��' TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 7 100 SEWER LINES ?100" DISPOSAL FLD.AwrPROP. LINE -- FOUNDATION 7_1QCL AGRICULTURE WELL OTHER WELL 1100/ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f! ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I--)- n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVL Specifications I'1 Public g0thor n Delta Depth of Grout Seal 2,0/ Type of Grou D 11 1 1 Irrigation 3�c�Apptox. Depth 11 Eastern Surface Seal Installed by Repay Work Done U Type of Pump H.P. State Work Well Destruction O Wen Diameter 2 a Sealing Material 8 Depth NtafG��rr�/ait�Dl?! -T_o 1+e�►r�e✓ra Depth '35 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sower is available within 200 toot.) Installation tint:serve: Residanco_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Dinanco to noarost: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size i1LTFoundation Property Lino SEEPAGE PITS 11 Depth Size SUMPS LI D' ost: Wed Foundation Property Lino NDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stato Lows, end rules and regulations of the San Joaquin County Home owner or licensed agent's signature eortifies the following: "I certify that in the performance of the work for which this permit is izzued, I zhall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature canities the following:"I certify that in tho poAormonce of the work for which this permit is issued,I shall employ poraons subject to workman's compensa- tion laws of California." The applicant/ for an requ' inepectiors. Complete drawing on reverse side. p� Signed X Titin: �"�(ri GCBs Sl Data: J 7 r ` FOR DEPARTMENT USE ONLY Application Accepted by Date Area Ph or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services RECLEI VEQ "" "3a7 445 N San Joaquin, P O Box 2009, Stku, CA 95201 �t11f / iJ..a INFO AMOUNT OvE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • Im 1124 IREV.1/11s1 fM 11.23