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APPLICATION FOR PERMIT y 2� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Io 0,11A- ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sm Joaquin County for a permit to construct and/or install the vork herein described. This application in made in compliance vith San Josquln County Ordinance No. 549 and 1862 and the Rules and Regulations of San Josquin,County Public Health Servlces Job Address �+ / S ,w City s /.mit 51 ze/Acreage �ji�� 2 '/ 9sd/S Owner's Name C�`-� tAddress —/3 3(`1 �L 14,.S � Phone j O (� Contractor Addres�D K Lill License No. Q U Phone A J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION FrDut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Lt- OTHER ❑ Monitoring Well L� 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wait Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications _ I'I Public I:1 Other f-1 Delta Depth of Grout Seal Type of Grout �. I I Irrigation / _Approx. Dep I J Eastern Sugacs Seel Installed by Repair Work 00" I)//Typa of Pump {,�„n H.P. J Stat Well Destruction !B" Well Diameters�-�1 f�lL Sealing Material i Depth ,ALT Depth 7- - Filler Listeria) i Depth J r , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INO septic system permitted if public saws, is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: —t Number o bedrooms Character of sod to a depth of 3 tot; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL❑ Method of Disposal Distance to mares t: 11 Foundation Property Lim LEACHING LINE ❑ No. 8 Length of line Total length/size FILTER BED ❑ Distance to nears Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well oundatlon Property Lim DISPOSAL PONDS ❑ 1 harsby 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 Sen Joaquin County Home owner or lice signature certifies the following: "I certify that in the performance of the work for which this permit n issued, I shall not employ any per rn such man as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Caftifiq the foing: "1 canity t t in the performanc a work for which this permit is issued, 1 shall employ persons subject to workman's compares tion lawn of ifornla." The applicant at ua �c let drawingon de. Signed X d- Ti �S!! "- FOR DEPARTMENT USE ONLY Application Accepted by , - - .. :�_-. - Date I Area f t Pit or y r -)Lnspec n by Date y Final Inspection by16'/J'//ff Date Additional Comments: tf�l' rn'/'2 �,',(:/�i�aj" /,� a ��.�/�.�nn fi �iir��.,G�/ l (1-T -64-2j" //1;1j,�6w Applicant - Return all copies to: San Joaquin County Public Health Services p/�� U(�- �' /✓J /f Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 d IlUy NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. _ ii qq _ �J IN IL'ix Hl Y ,7�� p✓ �% ` EN,4.211