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APPLICATION FOR PERMITFSR SAN JOAQUIN COUNTY PUBLIC HEALTHENVIRONMENTAL UEALTEI DIVISP O BO% 2009 , STOCKTON , CA 9(209) 468-- 3420 R eROW DATE (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct end/or install tht_ work herein described This application is made in cot;pliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services V Clry /1i2t.r->E-eT1I- A^J "J.•I` ',- "I"'," Job Address 890 E MAI KJ f 1 _ _ City STOCICTbIJ Lot Site/Acreage Owner's Name Address P 0 _a;;ayx 923_ STQ[ICTO(�__ Phone q40. 3 FAAJC Fid Contractor t Address Pd � 4X..32 LC=020A. 95'741 License No 4'Me � Phone � - - 95'5'9 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ out or Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER A Monitoring Well U �JlL F,3o�i./cr DISTANCE TO NEAREST SEPTIC TANK SEWER LINES _ _' DISPOSAL FLO AIM - PROP LINE FOUNDATION �.SAGRICULTURE WELL/4—/Z4— OTHER WELL,!Zd PITS/SUMPS Lvzd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation " Dia of Well Casing &Oomssuc/Prrvals 0 Gravel Pack 0 Tracy Type of Casing v ,5 Specifications r 13 Public bQ Other Cl Delta Depth of Grout SealF �� TYDO OI GfOUt_C,644GrnJ7• CI IrrrUation '4-IL Approx Depth ❑ Eastern Suriice Se,rl Installed by ,C'0 A-Zg GToiz Repair Work Done U Type of Pump H P State Work Done _ Well Destruction ❑ Wall Diameter Scaling Material i Depth .! Depth tiller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION 0 REPAIR/ADDITION 11 DESTRUCTION C1 (No septic systern permitted d public sewer is available within 200 leer 1 . Installation will serve Residence _ Commercial _ Other PAYMENT a w�[�Y, ENT r� Number of living units Number of bedrooms �° J � ' Character of soil to a depth of 3 feet ...._.W� tde3r' SEPTIC TANK ❑ Type/Mfg Capacity___ f��m�argnetrl�7 PKG TREATMENT PLT Cl S,4'1� i d rte^ ry Distance to nearest Well Foundation P e i?jI(tif i �r°r�ali* 1�p4139±r1+� ('E 5 IJr iti LEACHING LINE ❑ No 9 Length of lines _ Total length/size FILTER BED C1 Distance to nearest Well Foundation Propeny Line SEEPAGE PITS 11 Depth S+>s Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dura in accordance with San Joaquin county ordinances state laws and rules and regulations of the Sen Joaquin County, „ Home owner or licensed agent s signature cenifies 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 a 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 I shall employ persons subject to workman a compenss tion laws of California The applicafnt�Jmu call Opt all required Impactions Complete drawing on reverse side f \1 Signed u" Title row r Dale 41719 `f -- FOR DEPARTMENT USE ONLY �y �j� 1 -- Application Accepted by Data A�o / Area "' Pit or Grout Inspection by Date Final Inspection by Date v 0d1 w , Date \d�tlonel Comments I — S J5I _ ppllcant - Return all co lee tot Imo" \V D SAN J UIN COUNTY PUBLIC HEALTH SERV CE3 , ENVIRONMENTAL HEALTH DIVISION PERMIT/SBIIVICES 995 N SAN JOAQUIN, P 0 11OX 2009, 9TOCKTON, CA @5201 ``� i FEE INFO AMOUNT DUE AMOUNTrAEIMiTTEO Kit RECEIVED BY DATE PERM11 NO 1 `3Sor fH 1�7� Ix[V ii■!r Q it lJ`� 80( ��{(J -12-