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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONh=TAL HEALTH DIVISION ' 445 N SAN JOAQU.IN,,.PHONE (209)468-3420 P 'O BOX '2009,9',STOCgTON; CA 195201 PERMIT=E%PIRBS I YEAR FROM DATE IS JED (Complete iia Triplicate) r Application 1e hereby made to'$= Joaquin County for a permit to construct and/or install the work herein described. This application is made in co4liance with San Joaquin County ordinance No. 549 end 1862 and the Rules and Regulations of San Joaquin County Public Health Servicel. Job Address 3S Nor"' f k.crokC:t I-IXN%L City �da41 Lot Size/Acreage stuC- Owner's Name u(�jrRAta/ rIILt, 41 Address 4 7trri0,sf A-,41Phone &Zt-O2 1 � Conlrac4V14(L �iZra lu�is,',i1C .1 S / r Addfes� FLsL�_. iloya - �t2-License Na Piton 46 ,M TYPE OF WELL/PUMP: _NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ s ~ = PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' ( Monitoring Well k �DISTANCE 70 NEAREST: SEPTIC TANK Se. b• '^ S 3 +o S`OSEWER LINES DISPOSAL FLD. PO . LINE4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICATIONS I t.r. ... L-1 Industrial ❑ Open Bottom ❑ Manteca _ Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificationa ` I'1 Public f-1 Other "t- n Delta " Depth of Grout Seal Type of Grout I_I Irrigation Approx. Depth I I Eastern Surface Sea! Installed by Repair Work Done ❑ Type of Pump H,P. State Work Done_. Well Destruction ❑ Well Diameter Sealing Material A Depth _ Depth biller Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of Jiving 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. ❑ PAY MEMAW"Old of Disposal Q �.. .� Distance to nearest: Well Foundation LEACHING LINE ❑ N6.4 Length of linea 7�tt�llth z M .i FILTER BED e 0-.Distance to nearest: Well Foundation '.-- AN49AI i a " 1 F ALTM SE SEEPAGE PITS 11 Depth Sire P rr�utD��AL SUMPS LI Distance to nearest: Well Foundation Property Line i 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 lutes 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 shell not employ any person in such manner as to become subject to workman'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, I shall employ persons subject to workman's compensa- tion laws of California." _ The applican�t 'ust calf for all required i tions. Complete drawing on reverse side. _ � Signed ..• .%L- Title: tIt/i If J r Date: r m r �f C•�T rir/ v�¢i/i[�tI Ac. FOR DEPARTMENT USE ONLY F ~Application Accepted byDate A►ea Pit or Grout Inspection by 4` D Final Inspection by � Date 13-713-7ata Additional Comments: ' I _ I t•-� �-Applicant - Return all-,copies to: San oaquin County Public Health Services .. Environmental Health Permit/Services 445 N San..Joaquin, P 0 Box.2009, ,Stkn, CA 95201 I I .'.` ,• _ - FEE AMOUNT DUE AMOUNT REMITTED CK INfO• CASH RECEIVED BY PATE PEAMWNo.�'" /f7J(J • ,Ht«pCH 13-24 iIIEV.Fin51i3 qa