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(� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH': SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 9.5201 PERM TEIRE 1 YEAR FROM DATE SII (Complete in Triplicate) Application is hereby made to San Joaquin Couaty for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the:Rules and Regulations of San Joaquin County Public Health Services. Xj6-97S 6 U14 y W6S7-1006 Ode' EL D S�eK�iN Lot 3iae/Acree F Job Address City Owner's Name 11�V9 PAP CORP- Address Conlractw6� Af ' Address�H•Z d� ��'i i _ _ - License No. Phone TYPE OF WELLY PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION Cl Out of Service well ❑ PUMA INSTALLATION ElSYSTEM REPAIR ❑ OTHER C3 Monitoring titell DISTANCE TO NEAREST: SEPTIC TANK N� SEWER LINES �.____ DISPOSAL FLO. PROP,LINE FOUNDATION N/} AGRICULTURE WELL Arh OTHER WELL�Pe�L. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ff 0 Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well'Casing' 0 Domestic/Private VC Gravel Pack ❑ Tracy Type of Casing �• yes. �� Specifications' 27 I'1 Public Cl Other (I Delta Depth of Grout Seal`311 1. _ , Type of Grout to, TH I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Eee 0 ,"0 Repair Work Done U Type of Pump H.P. State.-Work Done •_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I NiNo septic system permitted it pkiblic sewer is i'available within 200 lost.I Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth x SEPTIC TANK. ❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wall Foundation Property Line Y. LEACHING LINE ❑ No. 8 Length of tinea Total tength/size FILTER.BED ❑ Distance to nearest: Well Foundation `Property Line -` SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to'nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f r•: t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state.taws, and ; rules and regulations of the San Joaquin County ,1. `" ry Home owner or licensed agent's rgnature 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 laws of California."Contractor's hiring or sub-contracting signature f 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." "` F The applicant must tail f r an required inspections. Complete drawing on reverse side. Ij . Signed Title:��5 T�', rtouK/wv�'1�2Y� ��+i• ,!Date: FOR DEPARTMEUSE ONLY a Application Accepted by Date Z Area L Pit or cheat Inspection by Date 1 2? 9 Firisi Inspection by �' '` Date l Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Servilces Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 20 kn,''. CA 95201 INFO AMOUNT OUE AMOUNT REMITTED CASH RDATE 'i PERMIT'N0. . . E14 t3.24 IRfw.1aS1 tK m42s 14'43 4.43 q3- .3