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APPLId-ATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �. JP O BOX 2009, STOCKTON, CA 95201 G PERMIT EMIRES I YEAR FROM DATE 1,I (Complete in Triplicate) Application is hereby made to San!4oaquin County for a permit to construct and/or install the *cork herein described. This application is snide in compliance ,vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Bervides. 1 Job Address �p City Lot Size/Acreage Owner's Name Address T�� AV& Phone F t T U, se No.t � `iTent] Phone F ��}Ci TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well IN ❑ PUMP STALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring well O DISTANCE TO NEAREST: SEPTIC,TANK-- SEWER LINES DISPOSAL FLD. PROP. LINE I I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ dustrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing -gg�asticlPrivate ❑ Gravel Pack..,; L7 Tracy Type of Casing_ Specifications I'I Public to Other n Delta Depth of Grout Seal Type of rout f I I Irri{lation _Approx. 0 1 1 Eastern /)H.P.L,-y�C` Surface Seal Installed by ' Repair Work Done 0 Type of Pump State Work Done_ Wall Destruction 0 Well Diameter Sealing Material i Depth .0 p f (-N Depth I Filler Material i Depth '"V AL) TYPE OF'SEPTIC.WORK:, NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public twwer is r " Installation will serve: Residence_ Commercial— Other s,� Number of living units: oms Number of bedro Character of t►ofi to a depth of 3 feet: j Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity ' No. Compartments Method of Disposal PKG. TREATMENT PLT.L7 ^� .� a Distance to nearest: Well a _ '" Foundation fA'` Property Line S ,v LEACHING LINE C7 No. 8 Length of lines' t Total length/site � l FILTER BED ❑ Distance tolnsarest: Wetl. Foundation Property line SEEPAGE PITS I I Depth l "Siie Number SUMPS Ll Distance to nearest: Wolf Foundation .Property Lina DISPOSAL PONDS ❑ 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.d_-_= Home owner or licensed agent's signature cenifiae 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 compents- tion laws of C ifarnla , The applic ust cal equir9d inspections. Complete drawing on rave side. I r Sig Title: Date: OR DEPARTMENT USE ONLY y Application Accepted byDate L4 ^ Z fl 1 ^ Area Pit or Grout In y Inspection b Data 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 O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE 111 AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. s � a EK 13-21 IRt:V.+swat � y EM 11.25 742r � � t r