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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED (Complete in Triplicate) T 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 A'O 33 1 5-0• 5T. To Ii ey f� L �. __ City lot size/acreage i� Owner's Name A 4422 to GVICA . Address A'o33 5r, :70 hA/ ^ Phone 38~ 30 A,), Contractor" A,1/how -1 501Y Address 6 002 Q�-+� � ��`9 - Opp License No. ��J_�-e�l _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT t-1 DESTRUCTION Ll Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ['I Public 1 Other (l 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. State Work Done _ Well Destruction 0 Well Diameter . Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION)fl DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.! ` Installation will serve: Residence-LCommercial__,_ Other Number of living units: __I Number of bedrooms .9 Character of soil to a depth of 3 feet: OetAld Water table depth S a SEPTIC TANK. 0 Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal �I Distance to nearest: Well Foundation Property Line LEACHING LINE N . No, 6 Length of lines Lma Total length/size 1 100 FILTER BED ❑ Distance to nearest: Well. /_4)0 Foundation Property Line '�t a SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cen4 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 canities 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 applicant st call for all required inspections. Complete drawing on reverse side. Signed Title: _ _ Date: _✓r` S' 9.3 FOR DEPARTMENT USE ONLY Application Accepted by _ Jwaf Date Area Pit or Grout Inspection by Data Final Inspection by Data S T Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ffrnVED BY DATE PERMIT'NO. INFO EM 3-24 /1 + EH 142611EY.1/851 �/ /