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APPLICATION FOR PERMIT SAN .ft1AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 /�P 0 BOX 2009, STOCKTON, CA 95201 > r r �� PDy � I li PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application Is sade 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 // City P" C'J neJLot Size/Acreage r 73 Owner's ame�a f ✓e4 t/ M PJ�es'_. dress 4�+� ^�✓ Pho461– O S`Foci�s•y..i Contractor t_k— l Addr sj 49-0A 192.71 License No.16 6 1-73 hone TYPE OF WELL/PUMP. NEW WELkIW WELL REPLACEMENT D DESTRUCTION MDut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ 00 t' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS (� El InIddystrial ❑ Opsn Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing W'Domastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications m I'I Public ❑ Other ❑ Delta Depth of Grout Seat Type, of�off Grout I I Inigation _Appiox. Depth I I Eastern Surface Soul Installed by L'n I�[,(1G(„(Q� Repair Work Done L] Jype of Pump H.P. tate Wo4 W4Done Way Destruction Well Diameter Sealing Material i Depth Depth Tiller Material L Depth 2 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 lest.) LTJ InsulLatbn will ssrw: Residence_ Coarc's'_ Other Number of living units: _ Number of M ome Character of soil to a depth of 3 feel: 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 C1 No. 6 Lengthoflines Total lengtvsize FILTER BED ❑ Distance to noaresC Well undstion Property Lina SEEPAGE PITS 11 Depth ize Number SUMPS LI Distance to ;sa, Well Foundation PropertyLins 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 employ any peso uch nrir as to become sublect to workman's compensation Laws of California." Contractor's hiring or sub-contracting signature chilies tM to "I chi that in Ihe perfo ante 00 a work for which this permit is issued, I shall employ persons subject to workman's companies Laws of alifornlal' -- TM spplic t must 1 squired s C late a verse side. art Signed K � � ' Title: "Y Date: '� R EPARTMENT USE ONLY {_�L/I Application Accepted by Q--I ems_ - P'�— Dste Area P� �� 1 "' Pit or Grout Inspection by \ _ 1, Date Final Inspection by rid_ 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 FEE I INFO AMOUNT DUE AMOUNT REMITTED CCK If RECEIVED BY DATE pPEAMIT'NO . EeU-Inairy fl • 00 (©o• Do 3Tf- 6f EH,4-I ViPI