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P APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES raj ENV I RONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 work herein described. This application is meds in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of Sen Joaquin County Public Health Services.( Job Address _ r Z +� �� f 2�__--- City Lot Size/Acreage — 6/1- L.e7-,f4. I Owner's Name lvellwlvallAddress U '�bx �`�O Z ��•^ ar CrSGdPhone Contractor __.Address ilr �J License fro. hone 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION D Out of Service Well ❑ W PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ --,, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS AL FLD. PROP. LINE } FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS INTENDED USETYP ELL PROBLEM AREA CONST TION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca of Well Excavation Dia. of Well Caning 1�! CI Domestic/Private ❑ Gravel Pack ❑ Type of Casing_ Specifications" I'I Public Cl Other fl a Depth of Grout Seal Type of Grout I I Irrigation _.Approx. De I I Eastern co Sear installed by Repair Work Done U Type of H.P. State Work Done 1 Well Destruction O Well Diameter Sealing Material 4 Depth Filler Material i Depth 7TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r!�ak ff 4/ �✓� sc'4eJ,,,,! Character of sort to a depth of 3 feet: / Water table depth " �. h SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal �a Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Tota) tength/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 rubs 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 foNowing:"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- lion laws of California." The applicant at for all req s ctions. Complete drawing on reverse side. / Signed Title: L�,!f�B�o� 1&-L9"�.c I 4&6,e Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ZZ tea fPit or Grout Inspection by Date Final Inspection Dat✓ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE � AMOUNT AEEM�ITTEO CASH RECEIVED BY DATE PERMIT NO. . EM 13-24 t11EV.tin sr s (! �=C/ z✓'-� �y� /� -� -�