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1� APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 2.2 S- 7 �[/ P O BOX 2009', STOCKTON, CA 95201 �+ q � t �0�� D CLS r'' PERMITEXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ecupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 08S C4 C) -) Job Address V_�t K R44 e , fe—k— City f7 Lot Size/Acreage � Owner's Name ` Address _3510 }� �Dl�CttUILlQv7 Phone -Contractor.--_ � - orf-- t�` dress--T�-�� -@�- 1 semicense_No_�: �-.Pttoee��' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION;?�Put of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring I ell ❑ DISTANCE TO NEAREST: SEPTIC TANK e7 e— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS armee N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca '� Die._of�Wall Excavation _ Dia. of Well-Casing FI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications +� I'l Public C1 Other n Delta Depth of Grout Seal '< Type of Grout " l I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done (.7 Type of Pump _ _ H.P. tato Wor ons_ Wall Destruction ` Well Diameter -;A=i Sealing Material i Depth to EvL I Depth �� tiller Material i Depth r,� TYPE OF SEPTIC WORK: NEW INSTALLATION�I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system'permitted if public sewer is i available within 200 Iset.l Installation will serve: Residence— Commercial— Other f Number of living units'. Number of bedrooms Character of soil to a depth of 3 fest: Water table depth N SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.C1 Method of Disposal h Distance to nearest: Well Foundation Property Line r 1 Z LEACHING LINE ❑ No.-$ Length of lines Total length/size FILTER BED 0—Distance to nearest: Well Foundation '` Property Line rQ SEEPAGE PITS I I ' 'Depth Size Number z SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ti J k 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 Sen.Joaquin County Homs 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." Contractors 64ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for.which this,pe}mit is issued, I shall employ persons subject to workman's companss- tion laws of California." The applicant must call for sit required i s , tions. Complete drawing on reverse sidle, r- Sig A Title: : T -�� Date: � S��> R DEPNT USF ONLYApplication Accepted by �9sewARTME -- Date __9 3L- Area Ph or Gout Inspection by Date Final Inspection by - d Data z7-q,? w Additional Comments -- - r-T• Applicant - Return all copies to: San Joaquin County,Public Health Services Environmental Healtli PermitLServi�ces 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201.. t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAT PERMIT'NO. INFO . EH 13.26(REV.I/x sr r_v 4 0� 5 ip EH 14-Mw v t '