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APPLICATION FOR PERMIT U 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 ISSU9D (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 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 "w� W' KeT7�� h L.��►C City Lot Size/Acreage - t/4 e-Wr_ Owner's Namey�r At ' Address Szs 4J 70/ 1 ~�C4 CA Phone knql 5- Z u J �j .?241 � �eiw/�{/�� tiayfn Z L o Contracto►r"e-le6!2t -&r At• Address 46#104 4. ae.✓a 1' 95 42- License No.�a2�2-• _ __Phon /� S�Z' f TYPE OF WELL/PUMP: NEW WELL it WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES >Sa DISPOSAL FLO.aI'b 4 PROP. LINE�0_-0 At FOUNDATION AGRICULTURE WELL OTHER WELL•] ' PITS/SUMPS ;,rG4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation/O za Dia. of Well Casing 4 rA * Domestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing 4�44" ^t: Specifications," 4i V] Public n Other n Delta Depth of Grout Seal A # Type of Grouter tom` I I Irrigation `!EJ9`Approx. Depth l I Eastern Surface Seal Installed bvr_-16,•r` A--r a� sX' Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 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 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(clawing: "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 is%"of California." The applicant must call for all requited inspections. Complete drawing on reverse side. Signed •x'` /�/ "� Title: e' • Date: 4LIZ Al Lu ~ � G~tV! ~ r 7or FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK If RECEIVED BY DATE PERMIT'NO. • EM M24 IREV.I/As) EM 14.21