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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 17 P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 APR PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 7- ,s I _ Application in hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application in 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 65 I S. H,,, Ael4,r BW. City_rretc.i - Lot Si ze/Acreage U n A c..j A Owner's Name Lc n e_, I,,r Address ?0- _6ox 6252 CA Phone ASIS 4-Z e,-4 bI 94SG6 Contractor Sam g11T%f, eec%el'i Sk—Address 53q3 Partite. 0114.4. P*,1.et.0CALicenseNo. Phone'At!Jg -;,)S-6?&! TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 9 Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK U A V�4oi,J A SEWER LINES JJtJkAoJA DISPOSAL FLD.QALU0-t PROP. LINE Z&- 100* FOUNDATION Vnknwl AGRICULTURE WELL OTHER WELLt_Zc0(D ' PITS/SUMPS Uk.%r'J"k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 14 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Oia. of Well Casing IlOwle- LJ Domestic/Private 0 Gravel Pack g Tracy Type of Casing 0041Z Specifications 0001- M Public X Other 0 Delta Depth of Grout Seal Anne_ Type of Grout 00%1e- C1 Imoation 10Approx, Depth 0 Eastern Surface Seal Installed by 1710A6 Repair Work Done L) Type of Pump Acne_ H.P. NN 0 St t Work Done_'n0 Well Destruction Well Diameter 1,4N Sealing Material & Depth fNoV,,JC. Sup I - %0, — Depth NA Filler Material 4 Depth Sic;,I - to' TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Commercial_AL Other Number of living units: � Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation— Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation— Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation— Property Line DISPOSAL PONDS 0 1 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 sub-contracting 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 applicant ust call for red Inspections. Complete drawing on reverse side. Signed X A� 1�I Title: V_A*JiCz,,1rAe,1LJ Date: 3 - 26 -q FOR DEPARTMENT USE ONLY Application Accepted by Date --- Area Pit or Grout Inspection by Date— Final Inspection by Date Additional Comments: 1t 'n iLZ UmArwr SAPL VL3 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-tJ�g-AK.1-to— - ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P 0 BOX 2009, STOCKTON, CA 95201 C" EC IVED BY SDATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CA INFO ql- pe2/1, r1210 111-24(REV.1/"5) 4.26