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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 V � 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. IN Job Address $ ; STI- e-.1— Cit k ' Lot Size/Acreage -r14 /IOwner's Name /u�!�!� / 1641-04V,0441 Address t0 7� 5. X, SST Phone 3—6:55 Contractor LLE NC-A Address--16,S 4--e- License No.-33—'Z/ Phone 47SI-4M-3/ TYPE OF WEF L/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION " "ofBerVice Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYP.E.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing; f:l Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications Il Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEV1I fNSTALLAT1014 / D I I system permitted it public sower is EX, P J:?J��Ptic le within 200 feet.) Installation will serve:, Residence_ Comm;tial_ `Number of living units!` Number of bedroo Character of aoa to.depthrrr�sie, nia of 3 feat: e expired Without water table depth SEPTIC TANK O Type/Mfg work 6Wdt i Water able depth nts PKG. TREATMENT PLT.❑ --._ -..- I b ivirorn jai Health Di�.'�i�n Ma�lod of Disposal Distance to nelsrest ell Foundation_ _ roperty Line LEACHING LINE 0 N6,":1 -Tength,,011inls Total length/size FILTER BED ❑ Distend -ton st Well Foundation I Property Line i SEEPAGE PITS I I Depth Size Nu}nber SUMPS LI Distance to nesrest: Well Foundation Pr _...._. operty Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordan a with San Joaquin county ordinances,state laws, and rules and regulations of the San Joaquin County Homs owner or licensed agent's signature osrtiftesithe following: "I certify that in the performan a of the work for which this permit is issued, I shall not employ any Wson in such manner as to become subject to workman's compensation laws of Cal forma." Contractor's hiring or sub•contrscting signature certifies the fo4owing:"I certify that in the performance of the work for"which'thiii pirrhit is isiued 1 shall employ persons subject to workmin 's compenss- tion laws of California." The applicant must call/for I required insPections. Complete drawing on reverse side. Signed Titl Date: t�•z -'' R DEPARTMENT USE ONLY Application Accepted by _ _-� c, '4 1 ►�M3� Date _ /2 Area .I�S Pit,or Grout Infpaction.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 2009, Stkn, CA 95201 _. _...... _ _.. _. ... FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INfO ��77 �/f► CASH Q/ • EN 3-24 111EV.1/M 51 EN tt 3 i>F /