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r. APPLICATION FOR PERMIT Irk SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE '' ENVIRONMENTAL HEALTH DIVISION stt jax: a P O BOX 2009, STOCKTON, CA 95201. ,JUN 3 Tal (209) 468-3447 ENVIRONMENTAL HEALTH k=11 EXPIRES 1 YTsAR VRQX DATE ISSUED PERMIT/SERVICES {( �o® N4,ge• (Complete in Triplicate) "q-,""J .. phe -�v o Application is hereby made,to San Joaquin County for a permit to construct and/or install the work n described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations or San Joaquin County Public{ Health Services. I f' Job Address - , rnt 1 U Ot L�Ch� YVII�e o�1�`Y]�T l�je�- City_ L4cL--- Lot Size/Acreage Owner's Name � R� 1�rzs Address lb'S 9 �• 1CKC___ Phone w�� Contractors L -� � �w`+0 Address 3 +`' License No's,-•?24/ Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public El Other ❑ Delta Depth of Grout Seal Type of Grout Xtrfigation _Approx, Depth ❑ Eastern Surrlaca-Seal Installed by Repair Work Done U Type of Pump j'StIA H.F. 7�[,� - - State Work Done _ a Well Destruction ❑ Well Diameter Dl rf Sealing Material & Depth t.sL}� Depth L3 Filler Material" & Depth p TYPE OF SEPTIC WORK: NEW-INSTALLATION-0 -REPAIR/ADDITION 0 -DESTRUCTION G (No septic system permitted if public sower is available within 2W fest-1 Installation will serve: Residence— Commercial_,___ Other Y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments q„ PKG. TREATMENT PLT. 0 t Method of Disposal Distance to nearest: Well _� Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 subcontracting signature certifies the follow in : "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 Calif, n I f The applica mu call for all requirinspectio Complete drawing on v se side. 7� Signed Title: Date: v R DEPARTMENT USE ONLY Application Accepted by Date L--S S� Area Pit or Grout-Inspection-by- - Date Final Inspection by Additional Comments. Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P b BOX 2009, STUCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PEAMIT'NO. . EN13•24 SREV.t i n st l�. O t� Jf/i'7JJ�! ,y I6•u 9 `' EH;4.26 -✓ �� /��'