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APPLICATION FOR PERMIT SAN JOAQ'. COUNTY PUBLIC HEALTH SERV :S ,1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE ( 209 ) 468- 3420 P 0 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 compliance with San Joaquin County Ordinance No . 549 and 1862 and the Rules and Regulations of San Josquin County Public Health Services . r1 Job Address p� G /�/L /7V 1` Ciity�J�C �O ^V ,Lot Size/Acreage If s/y 'T I�C2,E Owner's Name �' N'1 0 C 1+ PJ 1=10 4L Address tP L 1'3 [) /I r- lh/ C / I ✓ i= Phone il P. c , ,qex y431 r1 tDt ss3i� Contractor (7 / � �$ On/ p RI LL IAkAddress �f lrr lCry /+ i✓ pO �icense No Phone phone TYPE OF WELL/ PUMP : NEW WELL WELL REPLACEMENT 7 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER P� Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK A) Lt SEWER LINES L> DISPOSAL FLO. PROP. LINE / a t7 ! FOUNDATION (o ' AGRICULTURE WELL HILL OTHER WELL ..A4PITS / SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Ip-Industrial ❑ Open Bottom ❑ Manteca Dia . of Well Excavation Dia. of Well Casing z' ❑ Domestic/ Private WGravel Pack ❑ Tracy Type of Casing_ P J L Specifications I '1 Public ❑ Other 91welta Depth of Grout Seal F7 L Type of Grout CRM 6NT I I Irrigation L U � � Approx . Depth I I Eastern Surface Seal Installed by P ! Ede 50 L-e/ Repair Work Done ❑ Type of Pump H . P. State Work Done _ Well Destruction ❑ Well Diameter ,r Sealing Material i Depth Depth �a r Filler Material i Depth ( }' TYPE OF SEPTIC WORN : NEW INSTALLATION 1 1 REPAIR / ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet. l 1 Installation will serve: Residence _ Commercial _ Other C Number of living units: _ Number of bedrooms Character of soil to a depth of 3 fast: 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. A 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 cattily that I have prepared this application and that rhe 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 cartifies 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 certifies 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 Califemis." The applicant at all for M required 'nspecns. Complete drawing on re ei rse�ide. G Signed .J Title: �l + /', Date: � —•�— / 3 FOR DEPARTMENT USE ONLY cce -1 Application Accepted by Date Z-9 Area 2, Pk a Grout Inspection by Date Final Inspection by Date J Additional Comments: Applicant - Return all copies to : San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sao Joaquin , P O Box 2009 , Stkn , CA 95201 FEE AMOUNT DUEAMOUNT REMITTED INFO pLr�� '/'� ,{/7 V CE V D BY DATE .�PERMIT'�NOfj . E 13-24 (REV. i , eal F�, L/V (-J • `�lJ ZTII 3^ I(/73 9 { EN 1674 V