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-- - -----� � APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �(� C ENVIRONMENTAL HEALTH DIVISION .�'�r"` 445 N SAN JOAQUIN, PHONE (209)468-34gll' Cr,, �9g� P O BOX 2009, STOCKTON, CA 95201 g(� ,43 PERMIT EgpIRES 1 YEAR FROM DATE ISSIIID�C'�pQP�Y� �(�0\v (Complete in Triplicate) S�N\CA�PY� eef� Application is hereby made.to San Joaquin county fora permit to construct and/or install t erein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and t� as and Regulations of San Joaquin County Public fealth Services. Job Address A� Rc1QryT City Me Wt Size/Acreage 75-- �J rte_` s� n.�P.I C Sh CiGYA,;A ��gz7U SO✓r c kj( ,k �,-� Phone Z '3 �2 Owner's Name. �y�f M,,'l ,,II7 11 Contractor O e SO Address/«�A✓— 11 Maelty1e License9365 No.T/ /q Phone T 0� TYPE or WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well to• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �r f� ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,s,,�,,� DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL SiaZW— OTHER WELL PITS/SUMPS 6 it I ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Ois. of Well Casing ❑ Domestic/Private JR Gravel Pack ❑ Tracy Type of Casing, cl, 80 pVC Specifications I'I Public Ll Other n Delta Depth of Grout Seal QQ Type of Grout Pr fort �"r" I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by y 5:,.� �eR• az. Repair Work Done ❑ Type of Pump H.P. / K•P State Work Done _ Well Destruction ❑ Well Diameter 12 r, Sealing Material E Depth /orrss Depth 6J Filler Material i Depth ;A-gwaI 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 serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of so4 to a depth of test: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. E Length of lines Total length/size FILTER BED ❑ Distance to rarest: ; Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to rarest: Well Foundation Property Line DISPOSAL PONOS ❑ 1 hereby certify that I neve 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, 1 shall not employ any person in such manner as to become subject to workmen'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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant/must call for all required states; ns. Complete drawing on reverse side. Signed lr !L—i» Z. ' Title: lllJt4..ke.4, C2 64A;L�z✓ Date: / v R DEPARTMENT USE ONLY 7 Application Accepted by / L am— Oslo Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Q C Applicant - Return all copies to: San Joaquin County Public Health Services " S� Environmental P Perini 12009. see 445 N San tal uta, P O Box Permit/Services cesStkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY DATE PERMIT NO. NFO CASH GC7 � !0 2 �2-356`f EM 1}24 UEV. /eel { // �--