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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 PERMIT EXPIRES 1 YEAR FROM 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services/._ Job Address `^ r �°�7�,[C �Ll� '--�J City /�.�t�J� Lot Size/Acreage (JC J 1 Owner's Name !1/1 • f� 4a z o Address Phone Contractor Address 3,50 w• C �O icense No. -3 Phone 14plff,15k TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O 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 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth /w TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION IZ=MTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: R rice L—Commerciai ther (� Number of living units: Number of bedrm -� U Character of soil to a depth of 3 fest: 6 Water table depth SEPTIC TANK. ❑ Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE M--Ncr--b Length of lines /--P 0 / ` tai length/size # FILTER BED O Distance to nearest: Well�,[ Foundatio -ta S— Property Line SEEPAGE PITS I L,451;Wp-th Sire Nur2ber SUMPS LI Distance to nearest: Well J Foundation Property Line DISPOSAL PONDS O 1 hereby certify that t 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 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." Thea at 11 fo all t' lets drawing122 S pTitle: � Dato: `"y OR DEPARTMENT USE ONLY z Application Accepted by Date /4 ��,/f 2Area 2y Pit or Grout Inspection by Date Final Inspection by 2W4 ` // JJ-- Date /` _� Additional Comments: ► r: 61 �cped- l -1D,4gJZ�41k OU4,1rS�ir W;/ 7 '�Erdk f. i�-4> Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ll�flu)f ysl -^Mf ole �X 445 N San Joaquin, P O Box 2009, 3tkn, GAFEE SS552 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8V DATE PERMIT'NO. VaPIS . EN I124(REV.iiss1 f /� // t o��• EN 14.10 / �( L✓