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APPLICATION FOR 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 _YEAR FROM DATE_ISSUED (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 ceepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County-Public Health Services. ,! �Q Job Address ` + Sod!1 rf I7/� 4,"',SCN_ -- City Lot Size/Acreage s Owner's Name 0,L.e 77 !/A Address 02 5Y1? 4 Phone ?_94 U `74 Contractor M Address IN License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Die. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public l-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is Z available within 200 feet.) (� Installation will serve: R nce" Commercial_ ther "l Number of living units. Number of bedrooms D 3 0 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg L d A M - Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well l `D Foundation IIQ Property Line LEACHING LINE No. 6 Length of lines r Total length/size FILTER BED C1 Distance to nearest. Well /Ad!W Foundation I Property Line SEEPAGE-PITS 11 Depth Size Number S"Ro--- 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 rulas and rsgulationa of the San Joaquin County Home owner or licensed agent's signature cenifies 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 canities 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 compansa- tion laws of California." The applicant us call:foZrrK ctioA$:Com04ta drawing on reverse side. Signed Title: v Date: 3 —/ L oO'FOR DEPARTMENT USE ONLY -f Application Accepted by Date y 7--1 Area ;24 G.Q. Pit or Grout Inspection by ate Final Inspection by � Date / Addhkml Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Zo -v �•�� '1J 93•r__A Eft 11.20