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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCSTON; CA 95201.`� PERMIT EMIRES 1 YEAR FROM DATE Y"ifb� (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct rind/or install the voW described. This application is made in compliance with San Joaquin County Ordinance no. 549 and 184,2 d the Rules tions of San Joaquin County Public Health Services. C y j Job AddressJ�City �� Lot's�ps,(Agreage Owner's Name l�e(1 o' I Co^A l Address �M/TSS ;T. �Aj^ Phone Contractor IJ( ;n Address 0 f J� r\ (l�A bt�Cense ryo�(_ 5163°�hone—��J�'1 y '43 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well G PUMP INSTALLATIOP O SYSTEM RE�IR ❑ ,OT/HER ( monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �T_ SEWER LINES V� DISPOSAL FLO. N6 PROP. LINE FOUNDATION r�0 AGRICULTURE WELL OTHER WELL PITS/SUMPS LA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Q�/�✓�-S n Industrial ❑ Open Bottom Manteca Din. of Well Excavation Dia. of Well Casing 0� Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public 0 Other n Delta Depth of Grout Seal Ty of Grout �* � I I Irrivation 0 Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump P—_ H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth biller Material b Depth CAfi ,o�� Il9+. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I 1 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 sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ RECEIVED Method of Disposal Distance to nearest: Well Four"Ay 13 J9q1 Property Line SAN JOAQUIN LEACHING LINE Cl No. b Length of linea io I' /size FILTER BED ClDistance to nearest: Well_EN I R rWA3op�erty Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 shelf nor 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant1/fr__ust ca I f all required Inspections. Compt to drawing on reverse side. Signed X _tY.F"1 �'S � � � Title: -0 4) Date: —/7 F R DEPARTMENT USE ONLY Application Accepted by � — Date Area 77 Pit or Grout Inspection by to Final Inspection by Date Additional Comments: Applicant – Return all copies to: San Joaquin County Public Health O Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. EN p2a[REV.�r�Sr " F EM : -20