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APPLICATION FOR PERU'. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pub alth FJA94t40C.44 C2f4MP ENeI+GRP'f A/iob Address qt/-��) City Lot Size/Acreage 987— WG1R.�S �ownar's Name POWAC.._D H SEES 25 Address S R6 C Fie C-wGH (2 I'0 Pitons 0 ZGJ *ontractor 0C..E1 nim Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ �1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domenic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public fl Other n Delta Depth of Grout Seal Type of Grout 1 I I Irrigation _Approx. Depth I I Eastern Sace Seal Installed by Repeu Work Dome . Type of Pump �'S��A�j�r� H.P. State Work Dona_ Well Destruction ❑ Wall DismeleI Sealing laterial a Depth Depth L�0 Filler Material s Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is \� available within 200 loot.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soli to a depth of 3 feet: Water table depth (� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to mortar: Well Foundation Property Lim LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to rarest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby candy that 1 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 unifies 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 bacons subject to workman's componsation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa. tion Iowa of California." AThe spot cant 1 call®for/all required inspections. Complete drawing on reverse side. !J p U Signed IL /✓7fs*�� ./SJZdi9.J Title: - ocolfil jig— Date: 7 —2-Z 7 Z' - F DEPARTMENT USE ONLY Application Accepted by , Date Z= rsa-- 'y Ph or Grout Inspection by Date Final Inspection - Dat s Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sao Joaquin, P O Box 2009, Slice, CA 95201 INFO E AMOUNT DUE AMOUNT REMITTED K H ECEIVED by OA E PERMIT'NO. . EN 13-14 IaEV.tram IC 4'S.V �v✓ EH 14Ae