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APPLICATION FOR PEPWIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468- 3420 PE MIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mads to San Joaquin County for a permit to construct and/or install the work berein described. This application is made in compliance with Saw Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. �J C ,.,t. �4PN 125-loo-1-7 Job Address 2115-My wa• G1�/YCidr'i </• CitySp �SC:�i Lot Size/Acreage r1/0 ,4G Owner's NameS_'Ie(J 2 (�C/tey) -? I<t 2 Address �Z3L /4t'w e .A c:c, S-�cc,kdav,_LA Phone�41i- 7 Contractor Ayly= Address?—a-L&A, 27-3i 'RA4kQCct,fL^Ir License No.G'7L4� PhOC. - TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK i✓JA SEWER LINES 2.5 ' DISPOSAL FLD.N/,4 PROP. LINE FOUNDATION l.5 r AGRICULTURE WELL OTHER WELL PITS/SUMPS �ttl INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 2— Domestic I Private — Domestic/Private • 19 Gravel Pack ❑ Tracy Type of Casing PVC Specifications -T,- A 4y Q Public Cl Other ❑ Delta Depth of Grout Seal e'�' Ce Type of Grout_0/,7,-,0 - O Irr-gation ILApprox. Depth ❑ Eastern Surface Seal Installed by tti YGC�it/ Repair Work Done U Type of Pump H.P. State Work Done _ ` dlI Destruction O Well Diameter Sealing Material 6 Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/Ab01T10N ❑ DESTRUCTION Cl INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residents _ 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. Compartmants PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation __ Property Line SEEPAGE PITS 11 Depth Sire _ Number SUMPS l'•I Dislance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be dono in accordance with Sart Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the penormance 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 subcontracting signature certifies the following: -I 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." The applicant• us c II=111requ'ed inspections. Complete drawing on reverse side. Signed Title:6A)50..i AA.1 Date: FOR DEPARTMENT USE ONLY Application 701.dy Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Appllcant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 / FEE AMOUNT DUE AMOUNT REMITTEO K RECEIVED By OATE PERMIT'NO. INFO SH 006017