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I 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 EXPIRES 1 -YEAR FROM DATE-ISSUED (Complete in Triplicate) Application is hereby made to San i6squin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ) p� /Z X� �z City >�'1 g N�CC4ot Size/Acreage Job Address 444 _� 1 I Owner's Name�M Y� �l ►`[-Addres� �S r `� f-� —�� Phone Contractor 117, AI`2 ddresS �S V :�Xf License No. Phone �� ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ `_! SYSTEM REPAIR ❑ OTHER ❑ Monitoring,Well ❑ DISTANCE TO NEAREST: SEPTIC TANK "SEINER-LINES-"` '""" DISPOSAL-FLD. 4PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA ;-CONSTRUCTION�SRECIF)CATIONS 3. Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing J 11 Domestic/Private ❑ Gravel Pack ❑ Tracy � Type of Casing- Specifications Il Public [I Other (I-Delta �`bepth of Grout Seal Type of Grout e I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed,tm t Repair Work bone O Type of Pump "' '" "H P -- --State Work-Done- WellDestruction ❑ Weft Diameter Sealing Material 4 Depth. Depth Filler Material i Depth �f i. gTYPE OF SEPTIC WORK; NEW INSTALLATION 1-f--REPAIR/ADDITION I I DESTRUCTION l I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: -.Residence— Commercial— Other- Number ther Number of living units: Number of bedrooms 7: •- t Character of soll to a depth of 3 feet: or table depth SEPTIC TANK. .B Type/Mfg Capacity' '' Q o.-Compartments PKG. TREATMENT PLT.❑ rC, Method of Disposal N... Distance to nearest: Well Foundation Property Line t - ti a LEACHING LINE Q - No.fa Length of linea !� Toial Length/sire 'Z FILTER BED D Distanceto rtearetit� Well Foundation` Property Line ' SEEPAGE PITS I 1 Depth Sire_--- - - ="--- Number SUMPS',' --Lt. Distancs'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, an 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 at-to become subject to workman's compensation laws of Cslifornia.', 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,l shall employ persons subject to workman's corn nsa- tion laws of California." : The applicant must call for all n)quired.inspections. Complete drawing on reverse side. r r ESigned c Title: _% _ At r7 . Date: I - FORD PARTNf USE ONLY Application Acceptedbyr Date _ Ar Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant- Return'all copies to: San' Joaquin County Public Health Services Environmental Health Permit/Services - 445 N San Joaquin, PtO,.Aox-2009. Stkn., CA-95201 r�{� iF4 )FEE NFO AMOUNT DUE AMOUNT REMITTED C-CK "` RECEIVED BY DATE PERMIT"NO. r • EM 13-24 INV,fins) ' EN 14-W � i 47 o AO-e-7