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APPLICATION FOR PERMIT - SAN !TAQUIN COUNTY PUBLIC HEALTH a''sRV�CTB ENVIRONMENTAL HEALTH D I V I S I�((�� }} 445 N SAN JOAQUIN, PHONE (209)468 4#0 P O BOX 2009, STOCKTON, CA �Qib PERMIT EXPIRES 1 YEAR FROM DAT �1 //1lll�i (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �11 , �:JV. City �1Ci" r Lot Size/Acreage Ohrners-IJame C (� ��r (�1 n Address �2SO t-Vl -f 010 �l•Cl�. �� Phone =Z iA. Contractor t ' Address c' F + License No. t Phone LTC, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Ov PUMP INSTALLATION O SYSTEM REPAIR O OTHER $, MO O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP-t1N£ i FOUNDATION AGRICULTURE WELL OTHER WELL aP4T&SWMA6-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 1� Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specffl-JTZrW— F1 Public 1-1 Other ❑ Delta Depth of Grout Seal I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Artr Repair Work Done U Type of PumpH.P. _ r t,rr p Well Destruction O Well Diameter Sealing Material i1 Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms C WWftr of 00 to a depth of 3 feat: - — Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 Homs 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 sub-contracting 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 workman's compensa- tion laws of California." The applicantst call for all requir ins ctions. Complete drawing on rev side. Signed / Title: .- EVIG t 1'��L°� 1 Date: F D ARTMENT USE ONLY Application Accepted by Date r Area / Pit or Grout Inspection byDate Final Ins ction by C r �' Date /)-4-143 l/d / / Additfonsf Comments:/ a.6) 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 FEE� INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO.� 7Z �a l� EM14-M 1EV.riebt fH 1t�Q