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"! r) APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION . 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BC}% 2009, STOCKTON, CA 95201 t= TE S i ' 4 PERMIT E%PIRFS 1 FROM TE SU OFFS L ' I (Complete in Triplicate) E 0- Application is hereby made to San Joaquin County for &.permit to construct and/or install the vork herein described. This applfeatfon is made In cotrliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. (46'?A rt OF D4meS i 3 o,2iAVEsrrxro.t1 ( I I ck7J Job Address Gl City Sa Lot Sita/Acreage (Assoc,A•rED w orf/ A149L Y avc",llq rc"f cokAWY °i OAnar'e Name he SS -as 1Al'Es1C#A' O4 tr ISD N. StA)C1R/te Phone 3Address 1P, 01✓4L Wft'f 2 p. o. 053 C�oS Contractor ft'�Ll- �fzl'�t�� Address Bs4eeXSP1E4-DC 93380:V_A icense No. .'9"O/33_ Phone TYPE OF WELL/PUMP: !l- NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ is PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ;i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S /cE •&-Re-•2 industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /8 p �l Domestic/Private a Gravel Pack ❑ Tracy Type of Casing_ STIEEL_ Specifications M0Atrt"Ot n Delta depth of Grout Seal _ �Sy� I'll Public !Jd Oither Type of Grout I 1 Irrigation —II.Approx. Depth I 1 Easternl Surface Seal Installed by _tel✓SQL t�Is9TE�C �tI,-L Repair Work Done IJ Type of Pump JSdfi'�/Z5/&6 H.P. z State Work Done_ Well Destruction ❑ Well'Diameter Sealing Material i Depth I Depth Tiller Material i Depth ! TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 3 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 lest.) I !;Installation will serve: Residence— Commercial_ Other �tNumbw of living units: 1p Number of bedrooms Character of SON to a depth oyf 3 feet: _ Water table depth { SEPTIC TANK` ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 8 - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size ,I FILTER BED © Distance to nearest. Well Foundation Property Line `I SEEPAGE PITS 11 Depth Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O gyp, 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, staw taws, 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 iswed, I&hull 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 certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-tion laws of California." ip The applicant st ce ouired inspections. Complete drawing on reverse aide. t Signed �.- _ I'��DG , S3 Aq 1 Tills: _. TECH �+�La N!,,G Date: _ � DEQ k SdG' IA1c• FOR DEPARTMENT USE ONLY f n Application Accepted by Date Area Pit or Grout(dupe lion by Date 16 Final Inspection by- Additional Comments: W— P I Applicant - Return all copies to:. San Joaquin County Public Health Services s # Environmental Health Permit/Services 445 N Sha Joaquin, P D Box 2009, Stkn, GA 95201 I FEE H.� INFO AMOUNT DUE AMOUNT REMITTED CASH KIf RECEIVED BY DATE PERMIT'NO- 7` 511 €i EH 14-,V OA�