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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 9520 . (209) 468-3447 Y /On �� (Complete in Triplicate) %` Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein describede q This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and ReguliUS'J1s�of7ESait', Joaquin County jPublic Health Services, Services., 8' Job Address �� 7C L Lew-e-T r � City q-G' Lot Site/Acreage Owner's Name u- AM' Address _14 7�' YJ/fw-STT __ Phone UQ� Contractor =C L t s Address License No. lauayA Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Kell ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0, OTHER 0 Monitoring Well 0 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 SPECIFICATION / Ll lndustrisl ❑ pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin U Domestic/Private ravel Pack Tracy. Type of Casing Specifications A Z) ttblic C1 Other ❑ Delta Depth of Grout Seat +Q Type of Grout C P iR rgatiori —.Approx. Depth t_] Eastern Surface Sea! Installed by Q r Repair Work Done U Type of Pump H.P. AlAto Work Well Destruction ❑ Well Diameter Sealing Material i Depth r f S-� Depth Piller ilatbris,l i Depth t+t` J.. oaf• 7*b, %A,4 . TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION Cl fNo septic system permitted if public sewer is available within 200 feet.) 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 V SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT, Cl - ,, , , Method of Disposal _ Distance to nearest: Well Foundation ' Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED C.] Distance to nearest; Well Foundation +Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line <.DISP-OSAL_PONDS— .❑ - - _. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, hate Iaws, 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; "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 Cali ia." The applica must call f all ' ad inspgctions, Complete drawing on rev fee side, ay Signed Title: �� Date: t 4 FOR DEPARTMENT USE ONLY �2 16 Application Accepted by Date Aree Ili Pit or Grout Inspection by Date Final Inspection by Date Additional Comm6ntf:g/T r n; ra o ce. / _ A licant - Return all co� es to r w / d t �" ` 6 PP SAN JOAQ$I LINTY PUBL�C�}iAL SRV��S3� � ENVIRONIAENTAL HEALTH DIVISION PERMIT/SERVICES Ll`6 q c&4 / 445 N SAN JOAQUIN, P O 80X 2009, STOCKTON. CA 85201 SyF--6 2 c1 -�- FEE AMOUNT DUE AMOUNT FIEMITTED CK RECEIVED BY DATE PERMIT NO. 5�, INFO Q CASH f,J EN 13-24]REV.I/K 51 //�Q lqk �fJ� EN 1{.2e r �'''''� O�` �1 k—03 1