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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 O BOX 2009, STOC%TON, 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address -S>12-- R-,-,7-W Qe 4.) City FC— Lot Size/Acreage r Owner's Name f6[/2Ac- 0,-. u 4 i 7E PP G,Address d•47"et Phone - -dam' .STXit/ 4-2,i- Contracts FLO�eQ f- i,JVV D Address '7 A.I, iJ F>-6 B b�T .>�/,s� License No. 4426-7 4, Phone )4S--.S 9i I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by \\ Repair Work Done ❑ Type of Pump H.P. State Work Done_ W Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is / available within 200 feet.) r Installation will serve: Residence_ Commercial ✓ Other Number of Mang units: _ Number of bedrooms Character of soR to a depth of 3 feet: SAa'Ay 6-141 V k-OA t Water table depth SEPTIC TANK ❑ Type/Mfg ��7 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE W No. 6 Length of lines - 40 4 Total length/size 1_Z1471` FILTER BED ❑ Distance to nearest: Well 'AAI i" Foundation 14V I Property Line �r SEEPAGE PITS I Depth /O r Size X 1 7— Number 3 a SUMPS LI Distance to nearest: Welles fi- Foundation %CC f' Property Line DISPOSAL PONDS ❑ 1 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 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 Iowa of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 1lxrnr'c'l�t Title: Date: 4—Za -rT� % R DEP T �TE LYApplication Accepted by � —� Date -Ar r PR or Grout Inspection by Date Find Inspection to - — �_� Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Hoz 2009, Stkn, CA 95201 [NFO MOUNT DUE AMOUNT REMITTED CASH }f'R EECEIIVED By y/ DATE yl� PERMIT N0. r EH m211 IaEV.Irssl 4 EH t.al