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(�b-7 Z,;-b -(s s/�t&� �-rq70-4"-D APPLICATION FOR PERMIT Or/// A 11-Aa 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 X M FROM DATE ISSUED (Complete in Triplicate) Application is hereby Slade 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 _ _ Q dt "1City Lot Size/Acreage Owner's Name 2J�i �T�,S,2MXA y Address Phone Contractor Address lg- ,- License No F9.0 S 15 Phon - 6_'� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © Monitoring well C7 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public F1 Other V1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal lnstatied-by Repair Work Done U Type of Pump H.P. Sts to,Work Done - Welf Deettuction O Well Diameter Sealing Material L Depth Depth Filler Material i Depth "; W TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITIONK DESTRUCTION l I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence___- Commercial_ Other Number of living units: Number of bedrooms Character of soh to a depth of 3 feet: _ j Witertable depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal x' Distance to nearest: Well. Foundation Property Line LEACHING LINE Cl No. & Length of linea TotallHngth/sire FILTER BED ❑ Distance to nearest:, ..Wall .Foundation Property Line SEEPAGE PITS 11 DepthSite.__ ) Number SUMPS LI Distance to nearest:. Wail Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepareditiii-application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ruins 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 anyperson in such manner as to become subject to workman's compensation lives-bf-California."Contractor's hiring or subcontracting 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 Califorrils." The applicant 6calLfor all 'n tions. Complete drawing on reverse aide. Signed X 1dr, Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area -K r h or Grout Inspection by Date� � Final Inspection by 4 Date, �9 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EHt3.24 rREV. �• heel ` .� / ,©d � V> r fM 12a