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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 PERMITIs%PIRTyS 1 YEAR FROIM DATE ISSUED, (Complete in Triplicate) 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 cOmPliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. 34q Job Address City Lot Size/Acreage E Descriptliin_�hrlake/ r:,f1�oTvr �e / ^Ar I .a/:irn l /,,,-r - A Com ! -v._ I r j� Serial No. CAL. License No. CAL.-License Renewal No. Gal.,Wei hts &Measures No. +� r�anar^.it� s n_. 4 License No. a�2 J JWJ Phone - J TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT l 1/ DESTRUCTION 0 Out of Service hell PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK 5EWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION t # AGRICULTURE WELL` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industria! O Open Bottom O Manteca Dia. of Well Excavation I DrA bf tpalt-Crag— ;r Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- i- � 5pecificatians Il Public -----fa Olher »- ; { .pelta- Depth-of-Grout-Seal_- Type of Grout f I 1 Irrigation —.Approx. Depth I I Eastern`� , . � Surface-Semi Installed by Repair Work Done O—Typa of-Pump H'P. State Work Done Wali Destruction 0 Well Diameter Sealing Material i Depth �, I Depth Filler Material i Depth ' 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,I Installation wall serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms } a Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 1 ! ` No. Comps PKG. TREATMENT PLT.L7 .-�,- ' V Metf�f u Distance to nearest: Well Fpuridtition! pr' Li LEACHING LINE ❑ No. A Length of lines Total length/size - FILTER BED Cl Distance to nearest. Well Foundation . T � Properti`�r�yiShsl A�,�. 9 , i si. A� ^,aI SEEPAGE PITS 1 1 Depth Size ' i' " iNumbr r - ,1111N - ` SUMPS Ll Distance to nes rest:T,,,,dWell _ Foundation "'� ' Property Lina DISPOSAL PONDS❑ , '� Ni . I hereby certify th4t1-tffve prepaW-this appliation and'thit the work wdl"be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin county 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 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 foMo :"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 mla." The spill ant t call for all r7Q!d inspect Complete drawing on a, r erre Signed Title: t` r#lL Date: TFOR DEPARONLY :• 'f r , Application Accepted by Y�. Date Area Pit or Grout Inspection b f y Date Final Inspection by Date Z Additional Comments: `1 Applicant - Return all copies to: San 'Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEEr INFO ' AMOUNT DUE A AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO, CASH 77� 9 . E11 11.2 IREY.I/r 51 ?� �� EM 1424 » f/ J