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• APPLICATION FOR PERMIT • 61 AN JOAQIIIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 APR 15 NO P 0 BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTHPERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (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 in made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. // Job Address L_fL�� C �,/«� // /461L City L110,{ Lot Size/Acreage Owner's Name l� DM IYACX �7�t�Address Pd r A�ir 4W �ft Phone '4 Contractor "' Address &:; W, AWI) 46 A'2 ' License No.E �.)C" Phone --73 7V TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE61- P'r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Opan Bottom C Manteca Dia. of Well Excavation I Dia. of Well Casing ;>15cmestic/Private ❑ Gravel Pack C Tracy Type of Casing 4' 1-- Specifications I'1 Public ❑ Other r Delta Depth of Grout Seal _ Type of Groutl(�+Z^�"1L7J '� r 1 I Irrigation _Approx. Depth ./Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dona, WaN Destruction ❑ Well Diameter Sealing Material i Depth l3rr 7PN;C!- �'a7f"+�"7c%I �� Depth Filler Material a Depth �7 TYPE OF SEPTIC WORK: NEW INSTALLATION I • REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 lows, 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 porion in such manner as to become subject to workman's compensation lawn of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss� tion lawn of California." The applicant us cell ai alr7aq fired inspsc idns. Complete drawing on reverse side. Signed � �� Tine: �/'-zL/t�z% �Zac Bc=t�SrT Date: FOR DEPARTMENT USE ONLY _ Application Accepted by Date (//Z,O 3 Area Pit or Grout Inspection by Data Final Inspection by -•^^"'� Dat /C L/ Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services U Environmental Health Permit/Services �I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE /,(\ INFO AMOUNT DUE AMOUNT REMITTED �,,S/H IFR///EC�EIVED BY �JDA�TE PERMIT NO. . EMI]-7n IaEV.iixet J /�Jb i-rF.� I yl�U ^/SOV EH 11-H f GV 1