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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION p 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 LPERMIT .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. Job Address C,LUD k -- � L- -- --- - City &Pt I DkA Lot Size/Acreage - .1, r Owner Name -o L 5 !�-L Address � �� - Phone t Contractor g-1 A" it W! Address � L �16Luk—c-License No. 9(d Phone t TYPE OF WELL/PUMP: NEWiWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 ' DISTANCE TO NEAREST: SEPTIC TANK;I SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS .__.. INTENDED USE 'TYPE-OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1) industrial ❑ Open 8ottorn ❑ Manteca Dia._of;Well-Excavation -------- - Dia. of Well Casing C) Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing_ Specifications I'l Public I'1 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 L3 Type of Pump H.P. Stale Work'Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Tiller Material i Depth- '- 4 r TYPE OF SEPTIC WORK: NEW INSTALLATION Iq REPAIR IADDITION I I OESTRUCT10N I i lNo septic system permitted if public-sewer is available within 200.1601.1 ; installation will serve: Residence Commercial— -Other t . Number of living units: _L_ Number of bedrooms Character of call to a depth of 3 feet: k"`� Water table depth SEPTIC TANK. ❑ Type/Mfg l-' s �'.Q CapacityCLI No. Corttpsrtments j ! 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Prope ty Line-� y LEACHING LINE ❑ No. S Length'of lines 8 Total length/size v / k FILTER BED ❑ Distance to rtearast: Well Foundation Property Line 1 SEEPAGE PITS Ii Depth t _Size -i lie Number s%,l 5 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, on, rules and regulations of the San Joaquin County j 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 taws of California,"Contractor's hiring or sub•contrscting signature s 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 compenss- tion laws of California." The applicen mu_p,411 for ayroquired ' s tion Complete drawing on reverse side. . ^ Slurred Title: _ - _ Date: FOR EP RTMENT USE ONLY r i Application Accepted by Date ~3::M3 . Area 67 Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: 4 f i ? 4- e Applicant - Return all-copiesato:- San Joaquin County'Public Health Serices Environmental Health Permit/Services p 445 N San Jos. uin, .P O Box 2009, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOU REMITTED CK RECEIVED BY DATE PERMIT'hf0. 1 . EH 13-24(REV.1/a$) EH 14-m { i