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• APPLICATION FOR PERMIT . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOB 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EX95 7 YEAR PROM DATE TssUREI (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 cospllance with San Joaquin County Ordinance No. 549 and 1662 and the Rules end Regulations of San Joaquin County c�Public vHealth Services. Job Address ,z 7d1 /%A</7A2/'/VA. .00I City /A�eey Lot Size/Acreage /0A-e > Owner's Name GTPA/VO 04:zG5 Address �7A.wF U �^ ��1/ ,,.��// Phoned 83�-83Yo Contractor) R raw. 0-21 Iva Address a4 E,ZS�EAST/%�R]"t ze' License No.SIZA 68 Phone 65" 87/L TYPE OF WELL/PUMP: NEW WELL 39 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Z&16-2-1- SEWER LINES >.,Sb Fr DISPOSAL FLD.> 00 PROP. LINE ZF7' FOUNDATION -11_6-1 AGRICULTURE WELL RaOX'OTHER WELL SFT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation yu —X— Dia. of Wall Casing U Domestic/Private X Gravel Pack 9 Tracy Type of Casing -Xnio- Specilicationsdfa iys—o !T M Public Il Other ❑ Delta Depth of Grout Seal ;5,*01 Type of GroutcyMn IV017— CJIni anon U' AX,Apprgx. Depth ❑ Eastern Surface Seal Installed by GA.Awaty Acity Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter fa` — Sealing Material a Depth GW/f -A ed"I'll'i Depth 18 FT Filler Material i Depth �/4 S ex.o Fww�. 2 8 7s 7ferT TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION Ll DESTRUCTION G (No septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 lest.) Number of living units: _ Number of bedrooms Character of Boil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compentmeptl'„�` PKG. TREATMENT PLT. L) Method ol:Disposal Property Line Distance to nearest: Well Foundation r' ' - LEACHING LINE Ll No. g Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Wall FoundationProperty One SEEPAGE PITS 11 Depth Size 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 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.” Contractor's hiring or subcontracting 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's compensa. tion laws of California." The appfica�pt'Rlyst call for all required hispections. Complete drawing on rreverse title. Signed X `wwJ .f�ba-6n Title: f 4 `-cr Cm<ac-.,,r 8/4t ,� Date: --y' DEPARTMENT USE ONL FOR Y/ SS Application Accepted by Date / T o Q �Z Area Pit or Grout Inspection by Date 1.17I� Final Inspection by �•��/ Additional Comments Date Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON. CA 95201 1EEAZ D CASH RECEIVED BY DATE PERMIT NO, • ER U3.IaEV. irosl Z3 q5 D .�/ �/ O 5 EM 141a / '/ - [� 25�