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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES S'�p ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 j P O BOX 2009, STOCKTON, CA 95201 i PERMIT- EXPIRES- 1 YEAR FROM DATE ISSUPP (Complete in Triplicate) Application is hereby made.to flan Joaquin County for s 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 of San Joaquin CountyPublicHealt/h� Services. Job Address 1 9 �' '"�, L IV - City LC) ►, Lot Size/Acre t Owner's Name (° U ISL �M 1�. Address 118 ' LgLc L0 J_ ' Phone 3 G # % 1 COntnaClor �T" f f��^ G Address:F 0' I3 e X ) 9-)L7 �7* License No I�c 27� Phoned"Z C^1"J TYPE OF WELL/PUMP:', NEW WELL I r WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ! PUMP INSTALLATION 8_! a SYSTEM REPAIR 1:1 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK FOUATI /F3 C�-y SEWER LINES r DISPOSAL FLD. PROP. LINE ON—q�i_ERIC_L_ URE'WELT`�"�`-"OTHER-WELC_2_C—_/"=PITS"/SUMPS`— a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR CTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of V�l II Excavati DDia. of Well Casing r" D'Domestic/Private DK Gravel Pack 0 Tracy -Type of Casing_ Z T G Specifications \ I'I Public EI Other Fl Delta i;k Depth of Grout Seal X -Z C7Q Type of Grout��A17-6�Vf T I I Irrigation —.Approx; Depth 1 I Eastern 'Striace Sisal Installed by C�� G T a . .x l Repair Work Done L1 Type of Pump H.P_. Stats Work Done �_ Well Destruction ❑ Well Diameter 4 t3ealing-Material i Depth Depth biller Material.-A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ",, i available within 200 feet.) ` lTj Installation will serve: :Residence_ Commercial— Other Number of living units:,, Number of bedrooms Character of soil to a di;�th_o1 3.feat: Water table depth T SEPTIC TANK" ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` yMethod of.Disposal F Distance to nearest: Well Foundation Property-L-ine_ LEACHING LINE 0 No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth t Size ( Number i SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 Ilhe Home owner or licensed agent's signature certifies the following: "I certify that inperformance of the work for which this p0mil is issued, I shall not ? employ any person in such manner as to become subject to workman's cornat}}on 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 hermit is issued, I shall employ persona subject to workman's compensa- tion laws of Cafifornle." I The applicant nw all for all required inspections. Complete drawing on reverse side. Signed Date: = i FOR f] USE ONLY i Application Accepted by ' `- J Date Ara Z �` Pit Grout pection by data - Final Inspection by Date y 3 Additional Comments: 7`A 0- S "- Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services L,pl3 445 H San Joaquin, P O Box 2009, Stkn, CA 95202 ` FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT"NO. . INFO- _ _ _.�-_ - - GU�tl ;�_�, 4 4 ! J . EN 1IRf1r.„�5 :�..,.� 11 EN 11.2a4.25 ti J. k. -