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APPLICATION FOR PERMIT SAN FCAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 COPY ; P 0 BOX 2009, STOCKTON, CA 95201 f�r.I' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1• hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in Compliance with San Joaquin County Ordinance No. $49 and 1862 and the Rule, and Regulations of San Joaquin County Public Health Services. Job Address I4H`i City Lot Size/Acreage Owner's Name I.S , `REh1 i�t_S Address 9ZII K VV 'kG7,DZY 3LICTf Si.),f7 Q- Phone t kw�'�`_s-tom Ga `9 S 35b Contractor 1l-c-t n> Address S,� i C C, r•. aA ii License No.-<,-ZJy2? Phon TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Pf Monitoring Well ❑ DISTANCE TO NEAREST. SEPTIC TANK 1�'. SEWER LINES DISPOSAL FLD.-A4&6- PROP. LINE FOUNDATION / AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial O Opan Bottom 01 Manteca Dia. of Well Excavation Dia. of Well Casing 6?Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1:1 OOer fl Delta Depth of Grout Seal Type of Grow I Inigatbn Appox. Depth J I Eastern Surface Saul Installed Repair Work Done U Type of Pump T H.P. State Work Done _ Well Destruction ❑ Well Diameter � Sealing Material i Dept Ct7nE�Y, l�n.l� Depth R' Filler Material a Depth 0&-tzr)-crj-A--En..-- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within I.) Installation will ssrw Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of sod to a depth of 3 feet: Water ablePAtYMENT SEPTIC TANK ❑ Type/Mfg Capacity No. Compaml�Y! PKG. TREATMENT PLL ❑ EIVEM Method of1 D' s to nearest: Well Foundation Properly Lina -?W1 V 1 - CAN JOAQ111N!`01INITY LEACHING LINE ❑ No. 6 Length of lines Total lenoe t F PUBLIC HEALTH SERv,;,rS FILTER BED ❑ Distance to nearest. Well Foundatwn Prone & WONMENTAL HEALTH DIVIs.QNI SEEPAGE PITS 11 Depth - Si Number SUMPS LI Distance to 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 rules and regulations of the San Joaquin County Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not empty any perwn in such manner 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 issued, I shall employ persons subject to workmen's compents tion laws of California." The applicant must sill for *quit inspections. Complete drawing on reverse side. Signed L f ltx ti,`�C!?'�7Yd'.�G- Date: �9--Q Z TMENT USE ONLY E Application Accepted by Date Z Ar 301 3 Pit or Grout Inspection DY Dat Final Inspection by Dan Additional Commel G� Applicant - Return all copies to: San Joaquin County Public Health Services /, 00 Environmental Health Permit/Services 445 N Sam Joaquin, P O Box 2009, Stkn, CA 95201 //IN1EE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED 9Y DATE PERMITNO. 00 -EN taZl[REV,1/,sl //] 9 `_ 5r n "'f�i EN 4 a "I 3 93-0 O