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APPLICATION FOR PERJdIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1- ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) App) cation is hereby made.go San Joaqui° County for n permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Servic�ets..� 1� t/ 1 Job Address l�—C)`+"- O" v� i City`"� Lot Size/Acreage ' CZ,-) ,,�, ' n r Owner'a Name RanuA � LMS Address � r�t�pT CSC `�`��"�to� Phone Contractor lI(I�YYI Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ -WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SY TEM REPAIR O 40TH/ ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK +50" SEWER LINES / DISPOSAL FLD. _ PROP. LINE } 4501 PITS/SUM FOUNDATION �_ AGRICULTURE WELL �� OTHER WELL pc INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack O Tracy Type of Casing Specifications G Public Cl Other ❑ Delta Depth of Grout Seal Type of grout 1�C1�Ohl�t lP$ M IrnUation —Approx. Depth 0 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 Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION M 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$oil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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 California." The applies mus call for all required i pections. Complete drawing on reverse side. Signed Title: �/L. Date: Z �i F95 DEPARTMENT USE ONLY }� Application Accepted by Date_7-3- U 7 Area s �_ Pit or Grout Inspection by Date p ,D/ate Final Inspection b , c ' ,/Dattl�� Additional Comments: �?LX.C� lyi��`� n4 C� GtQ.t-t�4P f sem --- Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 INFO EEE AMOUNT DUE I AMOUNT REMITTED C K CEIVED Y / DATE PERMIT NO. . EH 13.24 111EV.v n pI Ja ! l Z ` EH 11.29 /