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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, Cts 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby tmde,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. l c/�� .. r4- Job Address 1 1) ( V j:2 / City 5TXn Lot Size/Acreage .moi j9aOwner's Name _�14)'r� 3� _ Address Illi S i I Z2 Phone t I Contractor rim E— Address /Z>2, /kW/ ��License No.,C/a�S Phone TYPE OF WELL/PUMP. V NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 Cl Industrial ❑ Open Bbltom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications D Public O Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irnga(lon __ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION El INo septic system permitted if public sewer is available within 200 feet.) CJ Installation will serve: Residence_ Commercial_ Other Rev Il/LQ 1-1�c.ILe IJ '16 Ylr Number of living unite _ Number of bedrooms Character of $oil to a depth of J feet: Water table depth SEPTIC TANK X Type/Mfg � 6Y7 Capacity/ �_pg No. Compartments PKG. TREATMENT PLT. Ll Method�^ of Disposal C\ Distance to nearest: Well Foundation� Property Line s1� X LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �{— SEEPAGE PITS It Depth Size Number (l SUMPS LI Distance to nearest: 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 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature candies 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 compansa tion laws of California." - The applicant must call for all rapid ms tions:Complete drawing on reverse side. Signed Title: E 3i Date: i _ FO EPAPTTME\NT USE ONLY Application Accepted by O&AlN -L. +...,c- \ Date 1� Q- `_C) Area Pit or Grout Inspection by Date Final Inspection by Date 0 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P O BOX 2009, STOCKTON, CA 95201 Nt INFO fAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY coo-(1-0 DATE PERMIT-NO. r14-76uEv.i..sl � 'L &6 \-,O(10 CA C� - 23 (�