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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ,34; PER1ffIT BUIRES 1 YEAR VRQX PAJEIS51JED Ib (Complete in Triplicate) Application 1a hereby made to S&w Joaquin County for a permit to construct and/or install the work herein described. This application Is made in coospllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address __I LALOS 9 k) � `��r"ti'�t7�_ �. City CA Lot Size/Acreage l ALte_`L --- Owner's Name Address !!5 Phone i Contractor o "-,Address Z5t 1-1 � License No, 9_(ja g t Phone -(OR TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing L] Domestic/Private ❑ Gravel Pack ❑.Tracy _Type of Casing Specifications M Public (-I Other i ❑ Delta Depth of Grout Seal Type of Grout C4 Irrigation Approx.,Depth 0 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done Welt Destruction ❑ Well Diameter) Sealing Material i Depth Depth Finer Material i Depth 51 t TYPE OF SEPTIC WORK: NEW'INSTALLATION 0 REPAIR/ADDITION DESTRUCTION D INo septic system permitted if public sewer is available within 200 feat.) Installation will serve: Residence_I.-Commercial Other ti'- Number of living units: Number of bedrooms ��S��J� G"'� i _ it Character of atoll to a depth of 3 feet: .- a.A a 1 T ^ Water table depth " SEPTIC TANK- ❑ T /Mf # e �^ /1.�,.�� ype g opacity__ - Na. Compartments PKG. TREATMENT PLT. C1 0� -' 'f _ ! po�,C vpriuti ethod of Disposal Distance to sa est: Well I Foundatio2 e kA4om 1 LEACHING LINE 0 No. & Length of lines L. 1�.nes Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O AmAX -i-.A-:) Q 4- 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 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 compansa• tlon laws of California." t The applicant`must call for all required inspections. Complete drawing on reverse side. Signed X Title: --- �� i -v�a��i r _ Date: T �- Ck ^q FOR DEPARTMENT USE ONLY Application Accepted by �*ZDate � Z Area ;+7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 22 1-2 4-S Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES a�� Qy4, yr 7 sx 445 N SAN JOAQUIN, P O SOX 2008, STOCKTON. CA 95201 � !�jC�✓ FEE AMOUNT DUE r' ,AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. INFO I CASH / . EH t3•H ittt?V.i/+t 61 ::-k1