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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 d / 9 6%,0 k14 6-? City Lot Size/Acreage Owner's Name Address 90-3 9� FAac�,Pul_ Phone Contracltx ddress cense No!`-'� Phone TYPE OF W LL/P MP: NEW ELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 C.I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth O Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION liff REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sawer is I available within 200 feet.) Installation will serve: Residence_LCommercial_ Other v Number of living units: _J_ Number of bedrooms_.42 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg `�' Capacity I NUM No. Compartments v ` PKG. TREATMENT PLT. ❑ __-1 Method of Disposal i Distance to nearest: Well l� D Foundation Ax Property Line l �D LEACHING LINE ❑ No. 8 Length of lines ^2 /' Total length/size D FILTER BED ❑ Distance to nearest: Wellrj,� Foundation J9 0_ Property Lined SEEPAGE PITS 11 Depth �✓ Size Number 11 SUMPS LI Distance to nearest: Well Foundation_ � Property Line DISPOSAL PONDS ❑ I 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 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 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 Colifornla." The applicant st I for all requir ,ins ctions. Complete rawing on reverse side. Signed Title: &:W Date: Al>v 441 &AAA �DEPARTIMAENT USE ONLY Application Accepted by � Date ' 1 t" Area 02 � L Payor Grout Inspection by ate <51 4inal Inspection b�� 1r� Additional Comments: 111 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEEO AMOUNT DUE AMOUNT REMIT-TEDCASH CK RECEIVED BY DATE PERMIT NO. EH 13-24 IREV.1/n e) ' l (� /( EH 14.14 �__