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APPLICATION FOR PERUIT ,.� ar 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 YEAR FROM DATE ISSUED rr (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f n rr Job AddressY71 L T1 hlesf bra At �`h,r� dad City � C Lot Size/Acreage Owner's Name /llraErud S TSjref yrs Address fi3/ &5eL&kAyG' I � Ti-QC (2,07) � -Q 6 1.r Contractor dress v 2- f r nese No..� z�6 Ph ne 145-19-112- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK AOA a SEWER LINES > 301515--f DISPOSAL FLD.�_ PROP. UNE/��Q'!�'s FOUNDATION � AGRICULTURE WELL AA— OTHER WELL_A — PITS/SUMPS 61 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationd Dia. of Well Casines %-R Domestic/Private `❑ Gravel Pack ')S Tracy Type of Casing_ ?I/L Specifications 1"1 Public 1`l Other I-1 Delta Depth of Grout Seal Prw-)+ Type of Grou tr I i Irrigation Z5 Approx. Depth I I Eastern Surface Seal Installed by _51!XC1tY`[1un a/ Repair Work Done U Type of Pump H.P. Stats Work Done, W@N Destruction ❑ Well Diameter Sealing Material A Depth �•, Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public serer is available within 200 feet.l Installation will some: 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 PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 ar Hone 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'@ c0rnMnsa- tan law@ Leafli The appl ret mr all equ'ed in t' Complete drawing on reverse side. SignedX Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date ar Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services a.r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM$T NO. . E,.,3-24(REV.1/0's) EH t�]a