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OV1�1}=v l,�olfl�, APPLICATION FOR PERMIT SAN�JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERI[ T EXPIRES 1 YEAR FR ;fit DATE ISSUED (Complete in Triplicate) 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� � `\ ` U E a City C Lot Size/Acreage ✓`�� Owner's NammitwWt!\ Address "z'-T J w`t@5A-1Lr, Phone C10 Contractor �5� $DX 1l71e ` si•� �• n License Nook " Phone`` ✓��' Address_�O TYPE OF WELL/PUMP: NEW WELL Nt WELL REPLACEMENT Cl DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑\/lg a 3)OTHHERR & (014onitoring Well IR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F�D.-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL � T'PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Psck j9 Tracy Type of Casii li tot 10% Specifications I'1 Public El Other n Delta Depth of Grout Seal `` Type of GroutG I I Irrigation —Approx. Depth I i Eastern Surface Seal Installed by 1'�WX Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 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. O Type/Mfg Capacity No. Com C PKG. TREATMENT PLT, ❑ Method o�1s Distance to nearest: Well Foundation Property Line RECEI Y�EI y�1,, -IITiT.. i_i._..f a LEACHING LINE CI No. & Length of lines �^ Total length/size FILTER BED ❑ Distance to rteanst Well Foundation Property ASH SERVICES EPWRONMEWFA644TH nnnclnni SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 laws, and rules and regulations of the San Joaquin county [ Home owner or licensed agent's agnature certifies the following: "I certify that in the perl6rmance of the work for which this permit is issued. I shall not employ env person in such iMnner as to become subject to workman'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 iseu d,I shall employ persons subject to workman's compensa- tion laws of California." 1,�, The applicant st all for all required in pisctions. Complete drawing on reverse side. —� ►rl. 6 Signed X l/� � Title: FOR DEPARTMENT USE ONLY Application'Accepted by Date �D'�'F ' Area Pit or Grout Inapeetion by Date Final Inspection by Date Additional Comments: Applicant - 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH p/�R.ECEIVED sy i DATE Q PERMIT'NO. . EN 114 111EV.�ieril 377 A1 <31 �[�,/„ �/�r` 1�� "'_`3 � 5EH11.25 �E' v