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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 NV 0 t+W�1A PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) .rV110 k,-W* ' Application is hereby made to Saa:`Joaquin County for a permit to construct and/or install the work herein described. This Joaquin Count San application is made in compliance with San Joaq y Ordinance No. 549 and 1@62 and the Rules and Regulations of pp Joaquin County Public Health Services. /+d) [� Job Address /cf• CTs, e., City Lot Size/Acreage Owner's Name Lc/e/ l`'"`�'/C�4_« Address 2 r 2 A f .a�� `� Phone �� 7 ontratttu!v° C6A y ! Address —_ 2-4-- License No.ta-5 6 p 9 Phone YPE OF WELL/PUMP: NEW WELL 'O WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well L PUMP INSTALLATI(Th 0— - _._ SYSTEM REPAIR 12 OTHER 13 Monitoring Well C] 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 r CONSTRUCTION SPECIFICATIONS 0 industrial O Open 80 tom• ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i'1 Public CI Other n Delta ^•-Depth of Grout Sea{ Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material A Depth Depth )-,+ °, A "s+ Filler Material i Depth ! TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO i INo septic system permitted it public sower is , available within 200 feet.) Installation will serve: Residence___.- Commercial____ Other L Number of Irving units: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �` No. Compartments i, PKG. TREATMENT PLT.Cl r�. r ` Method of Disposal r Distance to nearest: Well Foundation Property Line s LEACHING LINE C1 No. b Length of linea Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS I f -Depth �� - "Size Number SUMPS LI Distance to nearest: Well Foundation --- - „Property_Line - DISPOSAL PONDS O 4 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 j employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f 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." f The applicant st cal for •equked inspections. Complete drawing on reverse side. II nod% .- Title: 6 wsTrs.� urrc Date: FOR DEPARTMENT USE ONLY Application Accepted by __r= te _�' - _yDate ��'' y L Area Pit or Grout Inspection by Date Final Inspection by 5' Data 1 Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services k - Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. INFO 4 Q? /� I • E14 13.24 IREV.1/1151 t4� �� X535 1�� I G..- 9� — �J 0 k EH 11.26