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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BO%' 2009,_ STOCKTON, CA 95201 l � (209) 468-3447 !� PERYIv .EXPIRES 1 YEAR FROM DATE ISSUED s (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 coatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. y Thr-Tj? Job Address 5175 Z I-d2, City Lot Size/Acreage Owner's Name ^�J�F, /:R, _ gess � �E.d 1Jl.1s 2A►04 k wA tB Phone "'7 n/ 11 J Contractor 1 P,/1ianAddress :� faltAeAx_.CL License No,`� y Phone 1" 1401 TYPE OF WELL/PUMP: NEW WELL WELL"RE_PLACEM ENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION _SYSTEM REPAIR C] OTHER .1 W r O Monitoring Well ( DISTANCE TO NEAREST: SEPTIC TANK D SEWER LINES OQ I DISPOSAL FLO. �� PROP. LINE &O FOUNDATION 'P f AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS t4 n Industrial X Open Bottom C] Manteca Dia. of Well Excavation r Dia. of Weil Casing IF Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing- Specifications MPubtic I:1 Other p Delta Depth of Grout Seal �7� t7 Type of Grout2�ACk JAAIJt„ CI Irrigation ,_.Approx. Depth d Eastern Surface Seal Installed by 090142 kIF%/ C'f"'f Repair Work Done ❑ Type of Pump _S_u H.P. .*5—L State Work Done Y Well Destruction O Well Diameter Sealing Material & Depth f Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION 0 DESTRUCTION CI (No 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 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ► _ c SEEPAGE PITS 11 Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Home owner or licensed agent's signature cenifies 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 subcontracting 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 California," The applicant st call r all re uired ins ctions. Complete drawing on reverse side. Signed X ItTitle• L(�lx _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date vArea �- Pito�G�roInspection by Date Final Inspection by Date _�tJ Additional Comments: s Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES = ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES- 445 N SAN JOAQUIN, P. 0 BOX 2009, STOCKTON, CA 95201 FEE! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. f -r�4 0-0I�-� � 1 �� . EM tb7s TREY.1/Mb� 4 EH'.�.la