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APPLICATION FOR PERMIT SAN JVAQUIN COUNTY PUBLIC HEALTH S2AtVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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 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 _/L-yc�i �� d_i City Lot Size/Acreage i Owner's Nam ' -,,'{ Address -r'=ii✓1.(C>] Address 7' _fYl Connector t ,1 License No,y�1 �� Phone TYPE OF WEL UMP NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR AT OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 016 Donastic/Private Ll Gravel Pack ❑ Tracy Type of Casin g--- Specifications I Public 1-1 Other fl Delta Depth of Grout Seal 0 Type of Grout I i Irrigation _Appro.. DepthI I Eastern Surface Seal Installed by Repair Work Done , Type of Pumpli2�f� �� H.P. State ork 0 ne s'�' Well Destruction O Wall Diameter Sealing Material L Dept �t Depth Tiller Material i Depth _�j.r...{'�/ W !r5"e-2A33 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INT septic system permitted if public sewer is available within 200 leaf.) Instillation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of will to a depth of 3 fast: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments �\ . PKG. TREATMENT PLT. ❑ MethpAyAffi, Distance to nearest: Well Foundation Property LiA ® LEACHING LINE ❑ No. g Length of lines Total length/size ff7l FILTER BED O Distance to nearest. Well Foundation ProPe5AWnJ0AQUZLC0UNTY - PI IRI If u�Al TH SFRVI ES SEEPAGE PITS 11 Depth Size NTmberENVIRONMENTAL HEALTH DIVISION SUMPS LI Distance to hall Well Foundation Property Line DISPOSAL PONDS O 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 r employ any parson in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature ✓'t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss l tion laws of California.- The applicant mustcallfor ala r inspections. Complete drawing on reverse sid Signed X Title: b'�3rY+la-''Z Date: ��R O Application Accepted by Date �'�� as Pit or Grout Inspection 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 IFEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED eY O TE PERMIT NO. • EN 32414". /•v _ n