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�/ APPLICATION FOR PFRHIT R SAN �OAQUIN COUNTY PUBLIC HEALTH S VIES ENVIRONIIENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)4 34 P O BOX 2009, STOCXTON, CA 9 # PERMIT EXPIRES 1 YEAR FROM D TEMW �'O (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, S,e/rvices. / Job Address 7 �a''fT ��'�` "`S City SFOC1214. Lot Size/Acreage �?i (� -{, y� n ,RO 6 �� >P�/MIn IAEA prro 15 ra. Address a�ld -cLN.ct�t.o ICa.L�.ty� .S�vl�I',wPhone�! Owner's Name. --^-- -- (70 Contractor.- rif3 E �e/"Mrrobcoer`�1rAddress33 S rti G License NoCs7,9�.z69C Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTIONIR�Dut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES COQ- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Privet* ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public 6YOthern Delta Depth of Grout SealType of Grout I I Irrigation 5.5�Approx. Depth I I Eastern Surface Seal Installed by C., "S,;0/0 Jr /V cis. _ Repair Work Done U Type of Pump H.P. State Work Done Lel( Well Destruction Well Diameter /�� Sealing Material i Depth P mss/ lriJ Depth S^O •iCT Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation vAl serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.-1 PKG. TREATMENT PLT.❑ Met Distance to nearest: Well Foundation Property Li - fh youf gff LOU Al LEACHING LINE ❑ No. & Length of lines Total length/ FILTER BED ❑ Distance to nearest: Well Foundation Pro pryRYd AL pFEC SEEPAGE PITS 11 Depth Sire Number SS ry SUMPS LI Distance to nearest: Well Foundation Property Line 1^Y DISPOSAL PONDS ❑ I 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." Contractors hiring or sub-contracting signature certifies the fopowing:"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 laws of California." The applicant/mJyJs call for 0 required inspections. Complete drawing on reverse side. Signed M_r/�/H �,�_ Title: &all;,C e_ (ry_p1,9gr f T Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �'O Area �5.Q2_ Ph or Grout Inspection by y " Data Final Inspection by - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services -� iii�c.:u�• •='•' ' Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K S RECEIVED BY DATE PERMIT'NO. INFO 1 { CASH S ♦ EN 1124(REV.1/"ml EN N-M