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S APPLICATION FdR 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 PERMIT EXPIRES 1-TEAR FROM DATE T$SUED (Complete in Triplicate) Application is hereby amde to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance frith San Joaquin County Ordinance No. 549 and 1862 and the Aisles and Regulatiene of San Joaquin County Public Health Services. Job Address `1City s Ck— Lot Size/Acreage Owner's Name FL6WLMS MAAMAddress •Q SIS arL /KACC", Phone — Contracts : Address_ :-IT�CN 9S?!„r1L _ License No.. �Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C.-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0o,` SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C] DISTANCE TO NEAREST: SEPTIC LANK SEWER LINES DISPOSAL FLD. PROP. LINE '”" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r. 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (tloaomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public t:l Other n Delta Depth of Grout Seal Type of Grout 4 I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _g H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth i Depth Filler Material i Depth - -'-------- A J0rA f-PSIL TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No 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*oil to a depth of 3 feet: (�\ Water table depth SEPTIC TANK. t r 1 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 9 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 ❑ 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'a signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell 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 eartifies 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." The applican at call for all required inspections. Complete drawing on r rse s a. Signed Title: � QDate: jo FOR EPARTMENT USE ONLY �q Application Accepted by ZDate g- f Area 2-- C-0« 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 AMOOUNT REMITTED CASH NRECEIVED BY DATE P�EfRMIT'NnO.' EM 17-20 111EV,r/A O! ver f EH •2a 6— f f