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APPLICATION FOR PERMIT p SAN J(3AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PA P 0 BOX 2009, STOCXTON, CA 95201 (209) 468=3447 Pi+cels YEAR FROM DATE ISgUED SA2 (Complete in ;Triplicate) �N�PO$CV JOA U11VC;U NPY Application is hereby made•to San Joaquin County for a permit to' construct and/or install the vor LT �., This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an� s1*,S&n Joaquin County Public Health Services. s rc.� E$00E # 0 S�'irG City Size/Acreage ' IQCr� _ Job Address Lot Siie/Acre a nr Owner's Name I Address 11 ( S6ri LISt.J+ Phone 37Z-0 Contractor Address v E. Y JkLicense No. CS7"SJZz�hone y65~ 1Z TYPE OF WELL/PUMP. NEW WELL 29 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring, Well � DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES .! 50 DISPOSAL FLD.� PROP. LINE FOUNDATION AGRICULTURE WELL �2 OTHER WELL 50 PITS/SUMPS '-e-20_ .I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation S ___ Dia. of Well:Casing f U Domestic/Private @rGfavel Pack 0 Tracy Type of'Casing vC Spec if ications=ax b5-so M Public CI Other A Delta Depth of Grout Seal Type of Grou Cpmenf'bsnlgn ❑ IrriganRt;i n 0.11 Approx. Depth ❑ Eastern Surfs 9 Seal Installed by Asle)ti Ill 1A pair WFr4irl nJ U Type of Pump H.P. A State W rk Done Well Destruction ❑ Well Diameter { Sealing Material i Depth Depth Filler Material i Depth 9 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll . DESTRUCTION G lNo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �! SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl 1 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. 8 Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation - Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line iE DISPOSAL PONDS ❑ a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanc s, state laws, and rules and regulations of the San Joaquin County 6 Home owner or licensed agent's signature certifies the following: "I certify that in the performance Oft c thi a s issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California ' Co t for su ontra'cting signature certifies the following: "I certify that in the performance of the work for which;hilt permit is issued, I shat pi r bject to rkman's compensa• tion laws f California." '.I The apptic t m all f r wired inspections. Complete drawing on reverse side. f Signed Title: v Data: S 15 .i FOR DEPARTMENT US ONLY � Applicatio ccepted by ! D-.- at .5 zS-9 Area Q : Pit or Grout Inspection by Date Final inspection by 62& Date.' Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, .P O BOX 2009, STOCKTON, CA 95201FEE II INFO AMOUNT DUE AMOUNT REMITTEO CASH CK ..: RECEiVED BY DATE PERMIT NO.i . EH i3-It IIIEY.t i n Sir00 g9�11V tV ✓a. ` �'�`�1 I� EM 26 n t