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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PA YP4,Fjy P O BOX 2009, STOCKTON, CA 95201 RECES PERMIT EXP I RES 1 YEAR FROM DATE ISSUED 0 C T 20 19, .SP,, � {Complete in Triplicate} �.tOA,�L1P1�1 PUBLIC HF�1 CQJ� i 1' N Application is here Made to Sjoa uin Count for LF#r „r' App by q y permit to construct and/or inatal�r�2��1'x�j�[e�,e��ttn eecri1�e4 .$This application is made in complianee:rrith San Joaquin County Ordinance No.. 549 and 1$62 and the Rules an taii`litip ti�lb7 n Joaquin County Public Healthy,Services. Job Address �"�ILSI City S-FOCKW Lot Size/Acreage 110006 Owner's Name r� Ul��- Address L`KE\r,&b &0., = �` Phone 976 Contractor r i-iA b � fk Address `"t License No.55`f tPhone 9f -7276 TYPE OF WELL/PUMP: NfW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION Out of Service Well PUMP INSTALLATP ❑ SYSTEM REPAIR 0 97HER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKI��I —v SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - " PITS/SUMPS INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications (')'Public 1"1 Other 1-1 Delta Depth of Grout Seat Type of Grout I I lrrigation .Approx. Depth I.I Eastern Surface Saul Installed by Repair Work Done U . Type of Pump' H.P. Sta`t-e�Work Done Well Destruction Well Diameter 1r Sealing Material &.Depth. R60164r'r�__ okbjT Depth Sia I Tiller Material i Depth OX TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION [ I DESTRUCTION l I (No septic system permitted it public=sewer is available within 200 feet.) , Installation will serve: Residence_+ Commercial_ Other ` _ L Number of living units: Number of bedrooms Cr Character of soil to a depth of 3 feet: Water table depth �t�r SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length of lines Total Iength/size i T - FILTER BED II Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS= . ❑ r 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 not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub:corltracting 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 wiirkman's compensa- tion laws of California." The applicant all for r fired in Complete Complete drawing on reverse side. Signed X w A Title: AfEgi4 Date: R DEPARTMENT USE ONLY ~ Application Accepted by ' ` Date E Pit or Grout Inspector by Oeta incl Inspection by Date ` Additional Comments: Applicant— Return all copies�to:, San Joaquin County Public-Health Services v Environmental Health Permit/Services i .445 N San Joaquin,:P O Box-2009, Stkn, CA 95201 IFEE 0 AMOUNT DUE ±� AAMOUNT REMITTED CASH RECEIVED BY DATE PERMFUNO. x' /f�I G EFS 13.24InEV.1/: 6V`Q' © 4323 �— !e ?Z- EH Z'3..5 ` t4-m 1