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11 APPLICATION FOR PERMIT `R# age SAN JOAQUIN COUNTY PUBLIC HEALTHJr,I�fiS ENVIRONHENTAL HEALTH DIVIS u {f 445 N SAN JOAQUIN, PHONE (209)4 2 P O BOX 2009, STOCBTON, CA 9 PERH T EXPIRES l YEAR FROM DATE IWM (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work 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. Job Address 6i!5- City-5 001 Wt Size/Acreage 2ocjZS• TTZ Ownei s Name Ueyr"O A U9.4 r IIJ, tS Co. Address"Z 5116 COLO-;✓ln RCL~vel. Sc- �u��ione516 E -I - 9s Contractorsor sE eJv, Atldress 0 v 3193 Va.ea.✓rl� C License No Cf ,P2,4 Ti Phone 70 5"- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEB Monitoring Well ❑ s it So. vl`;0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESSo"Y T DISPOSAL FI_6 PRRROP. LIIFJIE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opsn Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public 1".1 Other (1 Delta Depth of Grout Seal Type of Grout t� I I Inigatfon _Approx. Depth I I Eastern Surface Seal Installed by rf Repair Work Done ❑ Type of Pump H.P. Stats Work Done Dtal C'i r ,S-21 y�vN!•19's Well Destruction ❑ Wall Diameter S Sealing Material i Depth hva.T Ce:4,r. T IT-0w O ro So V& Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ^n available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity partments PKG. TREATMENT PLT. ❑ R A 'M,�,,a,,,�h(ry Disposal �- Distance to nearest: Well Foundation—yl-��-Fropiri cone ri l'K .,g t 0w,h LEACHING LINE ❑ No. g Length of lines SAN'D6161(rkgg9{srre FILTER BED ❑ Distance to rlesnst: Well Found MBLVj lif AiRropa#y,uns, — AI.rib" Ch! SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state levee, and rules and regulations of the San Joaquin County Noma 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 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 Californla." The applicant must coil for W r ulred inspections. Complete drawing on reverse side. Signed X_ Title: Sdcir�C._ Cr ,1041S/T Data:v�� /R)DEPARTMEN7 USE ONLY � q4 Application Accepted by 1 f_I / '�-E'_ ( / Date L r `/ Area PR or Grout Inspection by Date Final Inspection by Date — Additional Commence: Applicant - Return all copies to: San Joaquin County Public Health Services �Pu4.� S:Zµ.4a eKar Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stirs, CA 95201 FEEINFO AMOUNT Ott AMOU/NT�REMITTED =CASHRECEIVED BY DAANTE . EH 1124(REV.1/AS) / 8 z51306� �•L/ / �1�� EH 14-21 V {•.