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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DAVE ISSM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This t application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City S` hot Size/Acreage 7 A5— Owner's Name MA k Jill 4622,0419 1 Address ` ,4_"ra Phone I .57XAl gs2.4S_ ContractorAddress License No.�2-4C2f Phone " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1Industri$I _ ❑ Open Bottom ❑ Manteca pia. of Well Excavation — Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack i, ❑ Tracy Type of Casing_ Specifications I'1 Public El Other r Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done {.3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth v@\1 r Depth biller Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) (� Installation will serve: Residence ✓ Commercial_ Other Number of living units: 1- Number of bedrooms .21 - 1C, Character of sol to a depth of 3 feet: G L A Water table depth SEPTIC TANK. ❑ Type/Mfg N CapacityNo. Corripartments 4 PKG. TREATMENT PLT.❑ �1 —.'— .11Y Method of Disposal Distance to nearest: Well ` :Foundation Property`L'ine LEACHING LINE ;I No. & Length of lines r Total langth/size A _ ., Y FALTER BED ❑ Distance to nearest: ''Well �� Foundation ILI - -- Property Line SEEPAGE PITS Depth Size i _ ,Number. -- — — - SUMPS CI Distance to nearest: Well Jne1 Foundation Z® � 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 d I 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. S rled !(_„ Title: Date: �! 3 FOR DEPARTMENT USE ONLY AA121 location Accepted by9 date I Ar ea I �r , Pito Groyrt Inspection by *Date Final Inspection by Data Additional#1 Comments: s Applicant - Return all copies to: San Joaquin County Public Health 3arvices�; Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASN ECEIVEO BY 9ATE PERMrr*NO. INFO / /� /" i I • EH13.24iREV.liriti !` v,lf�iri@A. 1H lade L fC