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APPLICATION FOR PERMIT ,saof SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is herebymade,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 �j.Joaquin County Public Health dServices. �n,� City /).ot Size/Acreage Job Address Owner's Name ,LE-24 r�C2e--- 2Zj Address �_ � � Phone sBNtrae /� ess, / � M !�I E' � E4 6� i 5 LGvio .P Ad TYPE 1�P OF WELL/RJ : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ of Servicee Well Ll ❑ SYSTEM REPAIR ❑ OT Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL F PROP. LINE FOUNDATION RICULTURE WELL 0TH ELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUSPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca DiExcavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications P] Public ❑ Other _ a Depth of Grout Seal Type of Grout M Irrigation —Approx. D th-- O Eastern Surface Seal Installed by Repair Work Done U Type mp M.P. Stats Work Don Well Destruction ❑ NI Diameter Sealing Material i Depth Depth Tiller Material a Depth STYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION ❑ INo septic system permitted it public sewer is h available within-200 feet.) Installation will serve: Residence Commercia Other ` Number of living units: --Z- Number of bedrooms I Character of soil to a depth J feet: Water table.depth SEPTIC TANK. Tyype/Mfg 6 - 4 Ceoac'ty 16 ,6 No. Compartments + .. � PKG. TREATMENT PLT.❑ - Method of Disposal L \ Distance to nearest: Well Foundation Property Line LEACHING LINE ¢( No. g Length of lines "-` ` Total length/size FILTER BED FIT Distance to nearest: Well/�D��" Foundation Property Line LSEEPAGE PITS W Depth r Sire _ Number SUMPS LI Distance to nearest: Well Foundation Property 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 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 compansa- ` tion laws of California." The applicant must call for all r9 ftiort/, omplete drawing on rev rse side. �N ✓ Signed X /J-!//_'.(s-.��"''r «/ (� Title: Ffy1p\\DEPARTMENT USE ONLY Application Accepted by Dace res r Pit or Grout Inspection by Date Final Inspection by9 Date 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 85201 FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BV GATE PERMIT NO. INFO `1 V �'j +/��.(� EH 1116111EV.rr66r l if A -� ' m t� '— �' 1 ' EN 16.2E lUltt