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U APPLICATION FOR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ` ENVIRONMENTAL HEALTH DIVISION � P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES-I YEAR PROX_PATH ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in collipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San , Joaquin County Public Health Services.00 ' 9 Job Address City ,A�4 J-f" - Lot Size/Acreage Owner's Name 02at Address f� 1�!t' GA 1 i,.A& 16.//?C,te— Phone Contractor G)Q04, 0J1S... Address # ��:1c2� License No. i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ Monitoring well [3 _DISTANCE TO NEAREST: SEPTIC�TANK SEWER,LINES DISPOSAL FLD. PROP. UNE I FOUNDATION AGRICULTURE WELL OTHER WELL PIT M, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t i fl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation st - _-- Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing t Specifications M Public I:l Other ❑ Delta Depth of Grout Seat Type of Grout yW-1-yf_ Cam~r r-I fmoation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. -„ State vyork Done ASAJ? Well Destruction ❑ Well Diameter 3ealittg Material i Depth ^ria Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L1 DESTRUCTION F-I (No septic system permitted it public sewer is t available within 200 feet.) , Installation will serve: Residence— Commercial_ Other Number of living units Number of bedrooms Character of *oil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No, Compartments I PKG. TREATMENT PLT, Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED n Distance to nearest:. Well Foundation Property Line n'� t SEEPAGE PITS I I Depth Sire Number Y SUMPS — i -EI—Distance-to-nsarest:.L Foundation--- -!= 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 Sen 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 Califor a." The appiica s a all required inspections, Complete drawing on reverse side. Signed Title: — i_t0 _ Date: �� 2'/ f Q Application Accepted by �FOD=ENT tlSf; ONLY Date 2-2 — r Area /T Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — Li Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1fV+t9 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES leg445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED GK1/6�/y'�+►/ �RECEIVED BY r1r DATE PERMII'NO. . CHI /// ROL /13-2/(NCV.iin Sr d•+. I • 131- EH:634 "�� /