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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC ECRAI.TH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOB 2009, STOCKTON, CA 95201 PMWIT EXPIRES 1 X= FROM D T 'I SII ` (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 Sus Joaquin CountyPublic /Health Services. Job Address ?,00 1 y �� EC City S_r�r?-0 Lot Size/Acreage ,f t _/�} 7 r } NO��Y . d �,,e� C 4 y�s�-p Owner's Name lft"/UI/7 r RO 01-fp. Address ��5� � T l& r " CPhone !O /-a Contractor R666- JXA- UG Address a 46MRI D�iVIEP License No. Phone iL TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION:U Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well M DISTANCE TO NEAREST: SEPTIC TANK AeA _ SEWER LINES Xm DISPOSAL FLD.N't _ PROP. LINE 3'�e fiy• r FOUNDATION &A_ AGRICULTURE WELL/V-A— OTHER WEL ee . (PITS/SUMPS e A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i a N L1 Industrial ❑ Open 8onom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private Id Gravel Pack ❑ Tracy Type of Casing Sed-* P✓r Specifications ['1 Public n other fl Delta Depth of Grout Seal '`f 3� � Typo of Grou T�.an'rr P, ?. Cute /carry I I Irrigation Approx. Depth t I Eastern Surface Saul installad by Repair Work Dane U Typs of Pump H.P. State Work Dome Sealing Material & Depth Well Destruction O Well Diameter Depth )tiller Material i Depth + TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 11ANo seplic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commerciel— 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. Comportments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of Pines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation '.Property Line SEEPAGE PMTS 11 Depth Size Number . SUMPS LI Distance to nearest: Wall 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 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to became subject to workman's compensations laws of California."Contractor's hiring or sub-contracting signature mortifies 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 Califotttla", The applicant must call for all required inspections. Complete drawing on reverse side. Sigma X Title- C ST &mw4v tAf4- rid- 'Date. // a FOR DEPARTMENT USE ONLY r " Application Accepted by Date ` Area Pit or Grout Inspection by Date Z S Final Inspection by i4 �'^'e"� _-- Date I ,k Additional Comrt+ents: MW F, 1 , f CD Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services " 2 .0V 445 N San Joaquin, P O Box 2009 Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED R EO BY DATE PERMITNO. INFO 17MS�71 i EN Si741REV.t/ttst�"{ � Oq- 1� -63010 47 � •3��/}a•,7 EN 14ab ✓��