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.-MEOW APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YF.0 FROM DATE ISOPED (Complete in Triplicate) 0,_(�Z Application is Ar-eby made LNo Sia 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 azd Regulations of San Joaquin County Public Health Services. /�'/L� Job Address GL /�City i r A6,n, Lot Size/Acreage Owner's Name L, 1 TLI l� 1 f N� Address N Y" ll�� AlePhone Q Contractor �! / y Address 900 U License No. -Phone TYPE OF WELL/PUMP: NE WELD WELL REPLACEMENT (l DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring well C] DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD.' PROP. LINE FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 industrial 0 Open Bottom © Manteca Dia. of Well Exca on Dia. of Well C Cl Domestic/Private $L.Gravel Pack El Tracy pe T of C in Specilications �Public t� Other Depth i CYw � � � � Type of Grou - �/� th o o Grout ea T/,� �� I I Irrigation '7!11rt�Apprft. Depth i ,stem 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 fest.l Installation will serve: Residence.- Commercial_._,_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line -� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lint 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, 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 nor employ any person in such manner as to become subject to workmen'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,1 shall employ persons subject to workman's compensa. tion laws of California." The applica t f all requir Inspections. Complete drawing on re a side.Af Signed Title: Date: F D PARTMENT USE ONLY Applrio�6 catlon A eptad bg Date 1 Area 40.v/�t/G �+G Pi.� Pit 010,10u9napection by riate Final Inspection by Date Additional Comments: C124k A plicant - 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 R.. aF AMOUNT DUE AMOUNT REMITTED CK FI RECEIVED BY DATE PERMIT'NO. INFOEM 13.241REV.i)n5l �9M 41.16 VV0 J-+ "