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3� a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA' 95201 F PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San.Josquin 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. 544 and 1862 and the Rules end Regulations of San Joaquin CountbkSc�Hlyh�trviccs. Job Address f a �'! (a b's *i' '✓z ��G� City SLC ` Lot Size/Acreage 74- Owner's Name 'rH—e Y1 19.7- P!►+7'M 48'.i f'� Address Phone ` // J r � Contractor �rt � C22C Z&AW Address_2LrZf � kL2��License No. 3,�f �S Phone J � p TYPE OF WELL/PUMP: NEw WELD . WELL REPLACEMENT [-] DESTRUCTION C1 Out of Service 1fe11 ❑ �} PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK J� SEWER LINES DISPOSAL FLO, PROP. LINE m� FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI {/ C1 Industrial ❑ Open Bottom ...��0///Manteca Dia. of Wall Excaval, Dia. of Well Casing Domestic/Private Gravel Pack l7t�Tracy Type of Casing_ C Specifications I I Public ,/f.l Other fl/ Delta Depth of Grout Seal -Type of Grout + I Irrivation y�L. Approx. Depth I I Eastern Surface Seal Installed by_11Ct_-0,Pi- .. ,, Repair Work Done 0 Type of Pump H,P. State Work Dona Well Destruction ❑ Well Diameter sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (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 Character of soll to a depth of 3 feat: 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 Cl No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest. Well Foundation Property Line ` Y F SEEPAGE PITS- 11 Depth Size Number SUMPS LI Distance to neatest:, Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the wo k will be done in accordance with San Joaquin county ordinances, state law:, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I rtify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman a compensation laws of California." Contractor's hiring or sub-contracting signature canifies the following:"I certify that in the performance of the work for which this permit is issued, I shall ampioy persons subject to workman's compensa- tion laws of California." The applican at ca for all r r Inspections. Com lets drawing on raver side. r Signed - Title: ...._ Dater 2y F DEPARTMENT USE ONLY .� Application Accepted by /Area Z Area Pit or spection by Date Final lnspectian by Date y ? Additional Comments: Y Applicant - Ret a all copies to: San Joaquin County Public Health Services ;y / Environmental Health Permit/Services a — / 445 N San Joaquin,,q ,' P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT'NO. . EM 13-24 IREV.r i n sl _I .i. .) �, r v .Z ,.��1 t EH 14.20 IN 1\/ !� y /