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APPLICATION FOR .PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH LTH SERVICES ENVIRONMENTAL _ ISION 445NSBOg 2009, STOCKTON, CAPHONE 95201PO PERMIT E%PIRES 1 FEAR FROM D T U (Complete in Triplicate) to Ban Joaquin county for a permit to construct and/or install the work herein described. This Application is hereby made, riLh Baa Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of n application is made 1a car> Joaquin County Public Health Services. J �C +� Lt/p�etC �,rll City-L-00-(t Lot Size/Acreage Job Address I 1 (1 �It .fL� / e� Q? 7nt45 21-QZ41 r '1 S2S &�i UrM 3 1 AAA, rv( CA /lZ.7r+Phon �/ 1 tfo-Wtat :f�i G _ Address C! I4 U .S.�r�!Z p Owner's Name y 3�4 F}L� `s 1 } ID8nOZ Gx �orr. t+C • Address Qa"` a °'� License No. , t of service well ❑ Contractor urnw WELL REPLACEMENT ❑ DESIRUC(�O` ftS TYPE OF WELLlPUMP: NEW WELL ❑ VO HAR ❑ Monitoring well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ SEWER LINES �— DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS FOUNDATION AGRICULTURE WELL k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS m O Manteca tt ❑ Open BooDia. of Well Excavation Dia. of Well Casing i C7 Industrial ❑ Tracy Type of Casing_ Specifications � Cl Domestic/Private 9 Gravel Pack Depth of Grout Seal Type of Grout ['1 Public 1-1 Other (l Delta i �.Approk. Depth 1 I Eastern Surface Seat Installed by 1 I Irrigation State Work Done Repair Work Done U Type of Pump H•P. of Sealing Material i Depth Wall Destruction •d Well Diameter Filler Materiel i Depth Depth system Mad it public: sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DES7RUCT10N I I alvailablerwit in 200 feet.) p Installation will serve: Residence— Commercial— Other k Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK. ❑ Type/Mfg Capacity^-- Method of Disposal PKG. TREATMENT PLT. Gl Property Lire Distance to nearest: Well Foundation � Total Iengthlsize LEACHING LINE 0No. a Length of lines property Line -�-�— FILTER BED Cea L-1 Distance to nearest: Well ^�� Foundation SEEPAGE PITS i l Depth Size Number SUMPS Lt Distance to nearest: Well Foundation— Property Line 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 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 net empty any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature employ the person following:"I nrtify that m the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- r tion taws of California." The applicant ust call for all required inspgctions. Complete drawing on reverse side.1 'L 3 9S /�c /.cf/ e. rC� Title: Date: Srg� !/a�t� FOR DEPARTMENT USE ONLY 1�7 �S' Application Accepted by Dots Area / Pit or Grout Inspection by Date Finallnspectio by Data Additional Comments: Applicant - Return all copies to: San Jo quin County Public Health Services �lh 2-,� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK RECEIVED BY DATE PERMIT•NO. 1 AMOUNT DUE AMOUNT REMITTED INFO el 0 c- p� ( �6 . EH13241illr/R6r Est 11.16