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APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby madli San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vi th San Joaquin,County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pu�3c He'lt 9ervlces.. '1�LA � seTb Job Addrs �T S'fbCl<To City 5CI<TCorJ Lot Site/Acreage , 11 •5 Ac Ri<5 Owner's Nam a PPc2T of S-it -Ca4 Address 2201 t/✓• W^S41NG"rLx.( Phone (Z[r W 0246 2A-7S CvGCa'TtF {3Jr _ (5foj 427' ContractorrZC66 ItJ"S`TU Address Sr�.1r}L- Nfl-t- 04 TL�� LicenseNo.G�'� Q�clItSPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ CMZ OTHER* Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES JA.UF,5 DISPOSAL FLO. PROP. LINE rrj�l MAP") FOUNDATION AGRICULTURE WELL ant OTHER WELLyr 55' PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I.1S rNW Dia. of Well Casing NA ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing NA Specifications f,A L7 Public fl Other Delta Depth of Grout Seal NA Type of Grou W: ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by NA Repair Work Done ❑ Type of Pump H.P. State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Cl DESTRUCTION G (No septic system permitted if public sewer is available within 200 feel.) Installation will serve: Residence— Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Pro rt ' LEACHING LINE ❑ No. 8 Length of lines Total length/size— FILTER ength/si a 2. FILTER BED LI Distance to nearest: Well Foundation Prop L h; SEEPAGE PITS I I Depth Sire NumbePij?I-'�� H721 ' SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ 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: "1 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 must co for all required inspections. Complete drawing on reverse side. Signed X_ Date:W Title: S7AGG !r�uwGsT Dets: �� ,F_41Cca..r -Sr'l` FOR REPARTMENT USE ONLY '/• 7C Application Accepted byr'r--J Date Areal) Pit or Grout Inspection byr� ale l �Y Final Inspection by ` ' '"' Date 7'� y Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES(/ L/ 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE .7 J INFO AMOUNT DUE AAMMOUNT REMi"EO �CCx I LRE�CEEIIVEErD 9Y / DATE Q QPEFIM17 NO. . EH Id•la laEV.i/ser 1E �� "G 2O — 4 J "<./ /�l� 1p � f• rA,21 En:68