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APPLICATION FOR PERMIT ` W SAN JOAQUIN COUNTY PUBLIC REALTR SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009 , STOCKTON, CA 95201 (209) 468-344-7 oRRMTT fiZEIRES 1 YEAR PROM DATfi ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �/ Jon Address ��/,, �(> J `" G"1✓:� �l� �/ U�� City 'y9/ 14/ Lot Size/Ac reage � C r^t- Owner's Name �'"`^' / / / O AddAddress �D �ox `' n!- 115�Ph �ons�GI� p / Conlranorw1111)1e,r,j o�-, 'f Address l D 0 dj0 x 3-3 Yc d2'i' V, SkA License No. �Q�6) % Phone T1' 37k-`I� TYPE OF WELLIPUMP UON WELL WELL REPLACEMENT 7 DESTRUCTION ❑ Out of Service Well C PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G 7 Industrial ❑ Opan Bottom ❑ Manteca Cis. of Well Excavation / Dia. of Well Casing U Domestic/Pnvate ❑ Gravel Peck C1Tracy Type of Casing , fl./C - Specifications ❑ Public '07-0ther So yi t� ❑.Delta Depth of Grout Seal �`f Tape of Grout GQ^eA ea J Inigatron Approx. Depth ❑ Eastern Surface Seal Installed by Rapau Work Dons ❑ Type of Pump H . State Work Dona _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Piller Material i Depth 7�-u TYPE OF SEPTIC WORKNEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Cl (No upbc system permitted d public sewer is fVn` available whin 300 feet.) Installation will sane: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to ■ Ospm of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrtants l PKG. TREATMENT PLT. ❑ Method of Disposal Q Distance to nearest: Well Foundation Property line C I LEACHING LINE C No. 6 Length of Imes Total length/size -} FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1) SEEPAGE PITS ii Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certrfy that I have prepared this application and that the work will DB done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner or licensed agent a signature certifies the following: 'I comity 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 subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I csrtdy that in the performance of the work for which this permit is ueued. I shall employ persons subject to workman s compensa- tion laws of California." The appeeant must c for all spurred inspections. Complete drawing on reverse side. Signed XCdr Tide: U.I I L C 2- Date: FOR DEPARTMENT USE ONLY -qM I { Application Accepted by r Date o`"- ` " Area Pit or Grout Inspection by ate Final Inspection by Date 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 2009, STOCKTON, CA 95201 FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 1324 isev i,.mil g is3 / ��a�3-9y ©o ll9 i I