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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_,JSSUED (Complete in Triplicate) i Application is here strode to San Joaquin Count for a pp by y 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 JoaquinCountyPublic Health Services. Job Address City04cLt1,A2a� Lot Size/Acreage Z" if Ae4,ev4 9,FWd7 i Owner's Name "ek., /,�a ,&!q0 u.A Address 9$Lt _&lee- Phone Contractor � 1 n! Address ae_ License No. Phone TYPE Of WELL/PUMP: NM WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well Gl PUMP INSTALLATION O SYSTEM REPAIR §e OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ; El Domestic/Private ❑ Gravel Pack E3 Tracy Type of Casing Specifications N -- --ll-Public -- f_1 Other --n'Delta— Depth-of-Grout,Seal— _Type of.Grout I I Irritation °.Approx. Depth I I Eastern Surface Seal Installed by q pot 0a Repair Work Done U Typa.of Pump _ rAJ6 6 _ H.P. State Work Done _. Q Well Destruction ❑ Well Diameter Sealing Material i Depth Depth I Filler Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is � 1. available within 200 feat.l Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Q Character of sou to a depth of 3 feet:. Water table depth � SEPTIC TANK. ❑ I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ 7� 1 r Method of Disposal �► Distance to nearest: Well Foundation Property Line r r � LEACHING LINE ❑ No.-& Length'df linesTotal length/size FILTER BED ❑ Distance to nearest:" Well Y Foundation Property Line SEEPAGE PITS 11 Depth Size : Number SUMPS Ll Distance 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, and rules and regulations of the San Joaquin County f 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 workman's compensation laws of California." 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, I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call for all required-i4papions. Complete drawing on averse side. Signed Title: A- Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area r Ph or Grout Ins pection 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, P 0 Box 2008, Stkn, CA 95201 {'I]FEE 1`A/M►'OUNT DUE AMOUNT REMITTED CASH :RECEIVED BY DATE l�PERMIT'NO.. . EH 11-21(REV.1/0%s i t' 1 r �' -� L T r frH 11•xa 1 f