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Fli APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �1! 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' IT EgPIRES 1 FROM PATE. SUED �! F (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a Permit to Construct and/or install the work herein described. This i application is made in eeailiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. iJob Address _- tIV j' r9.6 �l.a _ -------- __ City l-Dkw Lot Size/Acreage i Owner's Name .?l i-t ilty Address Phone 71? 7%3 Z� i Conlractor J-eb cam- GK&sS Address 1-6-10 t�- License Noq-773?.r Phone3 �If 11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION KOut of Service +tell Ll i PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK -t_la t SEWER LINES DISPOSAL FLD. t D PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS'/SUMPS �. {! s • INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Ind ris' 0 Open So"orn 0 Manteca Dia. of Well Excavation Dia. ofV6111 Casi7 a f I Oomsstic/P ¢kGravei Pack ❑ Tracy Type of Casing A� Specificatians...L.--` F I I Public -, rlvate,4 n Other (I Delta Depth of Grout Seat Type of Grout Ce.k7..C1-4 I I Inigatbri '�- "l�.Approx. Depth l I Eastern Surface Seal�rstalled t>y-- Cir-Trt,.�r. - Repair Work Done U„ Type of Pump LA9 H.P. —-_ 1 .,".State Work Done_ STE�ty Well Dest(uction Wall f)isrnefer"- `f- --"' Sealing Ifaterial A.Depth Depth 0 T Filler-Nater i Depth' TYPEOF SEPTIC,WORK: NEW INSTAL LATION,1 j REP4(R/A9DITI6N I I DESTRUCTION I I INo septic system permitted if public sewer is .I available within 200 feats Installation will some: Residence._ Commercial Other '\ Number of living units: Number of bedrooms Character of Sall to a dlpth of .__. _.--.. _.. .._. Water table dept SEPTIC TANK. 0 Tpl/Mf9Capacity No pseps<: -! 111 11 PKG. TREATMENT PLT.❑ ;Method:of Disposal } .. D itea'ta nearest:- Wei! Foundation Rropett Llae_`—_ -� JI LEACHING LINE Cl No. S Length of linea 7ota1 fengtiti/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Props" Line 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 Sen Joaquin County Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall not employ any person in ouch manner as to become"biect to workman's compensation laws of California." Contrector's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compenso- +fon laws of California." The applicant must c II for alt required in".ctions. Complete drawing on reverse side, signed >L_�.c�„-_ Title: Date: 3 l `�3 ! • DEPARTMENT USE ONLY` Application Accepted by 0& Date Area r-i-�F Iq Pit or rout nopection by Date -Wzt Final Irnpection by 0- Date V * Additional Comments: 'L / ✓ �� 1I 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 INFf AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE FERMiT'NO. 3.24INEV.1/K5i EH 144Ie 1H 13-24 .7 A /..ih h -r,..-. ..