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i 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 i PERMIT EMI RES 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t 33-J. 3 City L a CU Lot Size/Acreage 51�^ Owner's Name '+ Address Phone 433`t`SS� Contractor_ t _ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ : WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ 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 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` 0 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ r Specifications i'l Public I"1 Other 171 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by � i Repair Work Done ❑ Type of Pump H.P. State Work Done — Weil Destruction ❑ Well Diameter Sealing Material i Depth I Depth Filler Material i Depth r� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ( I DESTRUCTION I I Wo septic system permitted if public sewer is , / available within 200 feet.) Installation will serve: Residence�/ Commercial_ Other Number of living units: A- Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 1Er_Typs/Mfg Capacity I 2k 00 14-No. Compartments a ' PKG. TREATMENT.PLT.0 Method of Disposal + � Distance to nearest: Well LSO Foundation r%S Property Line l �I LEACHING LINE No. b Length of lines — ��t elf Total length/size r FILTER BED Distance to nearest: Well t� t Foundation _ SO_r Property Line f 0 0 SEEPAGE PITS I Depth ��c' I Size Number SUMPS Ll Distance to nearest: Well O Foundation O 0^_ PrSeM Lina 1 Q Q 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 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, I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature carlifies 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 spplica s or all required inspections. Complete drawing on reverse side. tk � y .5 f Signed Title: � { _..----- Date: 3 F T--USE ONLY pP A iication Accepted by -- Date � Area Pit !-„ Pit or Grout inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services fffl Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEI INFO AMOUNT DUE AMOUNT REMITTED CA PE RECEIVED BY DATE FERMI-VNO- EH 13.24 IREV,r/est tiH ta•2e L l P 0 i