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APPLICATION FOR PERMIT l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION k 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YE RAFROM DATE_ I S SUED (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 Sea Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address T i" �L-_Il �� _ City ��C�� Lot Size/Acreage ( /C/CL� [� /�'iI�" .s'7% s Ad /sem / wner's Name df� �1�C�A.+�fsE LJy/S Ac_ r4 .✓�Phone9 —/ r Contractor4la �BX cense No Ph?A 7 3,>'y V-3 O TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION iloscff of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 -7- Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dis. of Well Casing Z�y fl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ � Specifications I'I Public l-1 Other f7 Della Depth of Grout Seal Type of Grout �G.�oc+i I I Irrigation _Approx. Depth I I Eastern Surlace Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Naterial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) L Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 0Q SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal { Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of linea Total length/size { FILTER BED 0 Distance to nearest: Well Foundation Property Line J SEEPAGE PITS 11 Depth Size Number Q SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County (� i Hams owner or licensed agent'ssignature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not sntpby any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature candies the fohowing: "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 ins ns. 5p e ra ing on reverse side. Signed X, itl6: l�J Date: t FOR DEPARTMENT USE ONLY Application Accepted by Data "" a 1-4 � S Pit or Grout Inspection by Date 'ZZ' ?�Final Inspection by Date 3 /24�) t i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boar 2009, Stkn, CA 95201 FEECINFO AMOUNT/DUE AMOUNT REMITTED + CASHrr RECEIVED BY DATE PERMIT NO. EH13-21111EV.trNei UM 16.' Z, �2-ZS a EH 11.26 I