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! APPLICATION FOR'pERMIT SAN .JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 E (209) 468-3447 FXMIT WIRES 1,,.,YEAR PROM DATE _JSSM (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatall-the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County fPublic Health services, r Job Address y ` ` � AJ . ✓ City - Lot Size/Acreage Gly D t't Com_ {1 l's/L Owner's Nam _ `� � T' '7 3 �^! Address_ _ Phone e !!_ C. � ` �r' 1 r._ tri 1 St � .-� COntr.a_CtiOr,D �� 41(.�t�+.,+Cddress � • o'6.0 [a4`� L-=OCK '��11 p� isicense N0.4351 Z 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t1 DESTRUCTION ❑ Out of Service Well ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTfC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDAT16N, AGRICULTURE WELL OTHER WELL PITS/SUMPS [INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom 10 Manteca Dia. of Well Excavation Dia. of Wel! Casing ' U Domestic/Private ❑ Gravel Pack. �n Tracy Type of Casing Specifications M Public 1:1 Other l O Delta Depth of Grout Seal Type of Grout ' s �1 r , tJ IrripaFson — Approx, Depth H 0 Easiern _y�Suriaca 5.ea!`installed,by •� Repair Work Done U Type of Pump' `Y H.P. State Work Done _ waII,OestrucWn © Well Diameter ! Sfaling'Material i Depth e j Depth 4 `' ,_... Filler iMateri�eT <Depth "� "public TYPE OF SEPTIC WORK; NEW INSTALLATION r-REPAIRJADOITION Ci DESTRUCTION CJ INo se tic a stem erminr "� - r r"' ---�-" ' — 'available wi,hin 200 feet.l jlristallation will serve: Residence Commercial Other Numb�r of living units: _� Number o bedroo s f- ';Character of $oil to a depth of3 feet: j A✓ a/ `"''++ Water table depthfSEPTIC TANK tO Typo/Mfg I• � ` Capacity.,.,I.�p No. Compartments } PKG ,TREATMENT PLT. Cl f Method of Disposal 4 .^rl Distance to nearest: Well �" Foundation. ` property Line o -- i LEACHINrG LINE No. 8 Length of Lines 3 Notal length/sire Z IL-TER BED n Distance to 3 Barest: Well r Foundation -.�f Property Line ~' ,_7 (PAGE PITS 14 Depth Number .f SUMPS L4/ Distance to nearest: Weil Foundation_2:35'1 _ Property Line_? DISPOSAL PONDS ❑ I hereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws and rules and}regulations of the San Joaquin County Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation law$of California." Contractor's hiring or sub contracting signature lionlas the following: 111 certify that in the performance of the work for which this permit i$issued, I shall am fo tion iaws!of Calif rnia." f p Y persons subject to workman's compenaa- The applicant st it fora requir I s ion. ,_Camplele.drawing_on . verse side, _ ._ _ Signed Title: W ._ Date: vt �LJ DEPARTMENT USE ONLY �7 Application Accepted by / Date "��' n Arefl a t or Grout Inspection by ate r�� Final Inspection by Date Additional Comments: f Applicant - Return all copies to: j I P SAN JOAgUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 65201 FEE AMOUNT DUE AMOUNT REMITTED CK it INFO 7 �y� t CASH RECEIVED BY DATE PERMIT NO. • EM 14- IREV. r n sl r t V V i f 0� 45 7 3"~ 0 ?6 - v �