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APPLICATION FOR PERHIT_� �� /�t�v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIVMO— ` ENVIRONMENTAL HEALTH DIVISIO{�I�t 445 N SAN JOAQUIN, PHONE (209)4653426- I P O BOX 2009, STOCKTON, CA 95204 J TY PERMIT EXPIRES 1 YEAR FROM Dr T LQa- ' (Complete in Triplica , 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 Country Public Health y�Services. , • / 1.y T Job Address 7s�aST Lt4_; 9 t J0-/ Cit�i��,&* Lot Size/Acreage ('+_Q,.,„,,,, Bob GoKde k Owner's NameCI�F_ ` USh Pr��TS CS�,O, - Address�ylo COL�r40 -Ste' �a� hone b 2-' 2 L Contractor k dies S n sure• C icense No�1.9' 6gC Phone&07 qSl-C/2l TYPE OF WELL/PUMP: NEW WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6a-�1_ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 91/1' Dia. of Well Casing 46<Domsstic iv_810 ❑ Gravel Peck ❑ Tracy Type of Casing S¢�^. yb pvC- Specifications I'1 Public s1 well Other N^ ,h16) n Delta Depth of Grout Seal 2'-7of Type of Grout iJa I I Irrigation ,.,,'''' h/�r Depth I I Eastern Surface Seal Installed b �i�c EXn�a/YLr7_nw �e✓vl icr-f �'w�. 1g .r�i w'ppox. De V — Repair Work Done U Type of Pump H.P. State Work Pones ll =1rs1_.A1 rtilar+�1an1 y We/ Well Destruction ❑ Well Diamet r T Sealing Material i Depth vu vAes a441- Depth Tiller Material i Depth #7 EaA- -10 7b 21 -Pr TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Going units: _ Number of bedrooms Character of soil to a depth of 3 fest: —Watetau SEPTIC TANK. O Type/Mfg Capacity— No. PKG. TREATMENT PLT.❑ Method of,Qjtggsa� Distance to nearest: Well Foundation Property Line NN�U Yy 9 1993 ENVIRONMENTAL HEAtTH LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby comity 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 Homs 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 comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- Non laws of California." The applicant It call for a"r urr inspections. Complete drawing on reverse side. JJ Signed X T Title: ,l73 58c%tt/rim �a2,1 1T Date: l/ OR DEPARTMENT USE ONLY �j Application Accepted by Date Area " D ' Ph or Grout Inspection by �r Date Final Inspection by ^1�Date Additional Comments: b` t' s�T� w CLJ- / Pend COS G� 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE RECEIVED BY GATE INFO AMOUNT DUE AMOUNT REMITTED CASH PERM�IiT'N0. . EN 1V.1/SSI EN 163!4.33 L 1 16 ✓l6T CVJ