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APPLICATION FOR PERMIT y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIIENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 (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 csde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Jooquln County Public Health Services. L, j� Job Address 9Qq 9 S'r)UA I �Wy-fhu✓ K)Ood Ciitty MCS4 Lot Size/Acreage Owner's Name A. Ti 2Ghet4 4 SOn ru►'C Address� J� Phone = f60 i,W cr�tM54 `�' �qi6 373-t t Contractor Address 'd a License No. Phone Z-� TYPE OF WELL/PUMP: NtW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well rr DISTANCE TO NEAREST: SEPTIC TANK ASO SEWER LINES >570 DISPOSAL FLD. a PROP. LINE :iP J'' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rPG M011 f' LAeJ C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f6inch Dia. of Well Caving 2 I n ;kl Domostic/ rival C) Gravel Pack /Tracy Type of Casing_?VC Specifications l I"1 Public Other n Delta Depth of Grout Seal qf) TC-G Typo of Grout naALCM&I I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by .D'i k-r-5 Repair Work Done ❑ Typo of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing thteri.al 6 Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will servo: Roaldenco_ Commercial_ Other Number of living units: Number of bedrooms Character of call to a dspth of 3 foot: &TC C^"j% nth SEPTIC TANK ❑ Typo/Mfg Capacity YC." s� s PKG. TREATMENT PLT. ❑ sal Diatanco to nearest: Well Foundation Prolf ir8 LEACHING LINE C1No. A Length of lines Total Is JJ FILTER 8E0 L-1Distanceto nearest: Well Foundation poll, t I�Tr1YI HEALTH d � —ME SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to noerest: Wall Foundation Property Lino DISPOSAL PONDS ❑ 1 hereby conity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County Homo owner or licensed agant's aignatura certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any poreon in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cenifica the foWwing: "I certify that in the porformanco of the work for which this permit is issued, I shall employ persona subject to workman's componsa- tion Iowa of Celifornia." The applicant s all for to roquir inspaptions. Complete drawing on reverse side. q Signed X /� C�— Title: (2,y Date: �� R DEPARTMENT USE ONLY Application Accepted by Date 1 Pit or Grout Inepoction by , Date Final Inspection by_ �' to J� Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE PERMIT'NO. . EH 17.24IREV.1 5) �vl O itis EH 1147