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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SCANNEP ENVIRONMENTAL HEALTH DIVISIONCiv 1,. P O BOX 2009, STOCKTON, CA 95201 (209) 468-$4*r 3}/'ap PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work here4iZ described. This application is Sade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatlons of San Joaquin County Public Health Services. Q Job Address 12:54 • City Lot Size/Acreage ( Owner's Name s"'QEs' >6;2 ik] Address PC �7� K � Phone -1 376 ConUacto '�fd�Address License N403962— Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION �VC- SYSTEM REPAIR 7, OTHER p Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irugation —Approx. Depth ❑ Eastern Surf$ce Seal Installed by Repair Work Done Y-- Type of Pump./.,jam--! H,P. dka- - State Work Done - -C�-r1��ttti✓sa!o Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is available within 200 Iea61 Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 6 Length of lines Total length/Size n FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 hereby comity 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. 't 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 wo(kman's compensation laws of California." Contractor's hiring or sub-contracting signature canities the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persona subject to workman'*compensa- tion laws of California." The applicant mus a for all to uir d inspections. Complete drawing on rayarm side. p Signed XDate: 1>�/ L+ Title: P ! FO EPARTM ENT USE ONLY Application Accepted by `� Date Area Pit or Grout Inspection by Date Final Inspection by Date 2 (4 rL Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 INFFEO AMOUNT DUE AMOUNT REMITTED [ASH RECEIVED By DATE PERMI7 NO. . EH 12.21IaEV.rr.mi �� 0) F,EH A.2111