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APPLICATION FOR PERMIT SAN iAQUIN COUNTY PUBLIC HEALTH osRVICES rL�� (� ENVIRONMENTAL HEALTH DIVISION n • 445 N SAN JOAQUIN, PHONE (209)468-3420 V- _ P O BOX 2009, STOCKTON, CA 95201 dSZS 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 vork herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address O C ST. City T\rte C Lot Size/Acreage ~/ Owner's Name` Ncv�w 1 �+c�� Yy�S Address a�a "1 F �yT / r�Phon.Q--, Contracts lvn5iZ Address CL0 �License No. -E7 Phone' W'--7'Z TYPE OF WELL/PUMP: NEW WELL ❑ WE C REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION SYST�E,MJRWPAIR ❑ ;OTHER ❑ Monitoring Well � DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLO. �1� PROP. LINE 2-0 FOUNDATION � AGRICULTURE WELL _AZ�� OTHER WELL PITS/SUMPS �1✓ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X 11 `a L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ►^C,N Dia. of Well Casing [I Domestic/Private 'Gravel Pack Tracy Type of Casing_ rtt Specifications ��+ HC S I't Public fl Other n Datta Depth of Grout Seal 1 rt Type of GroutA 6fiL Ccwtth� I I Irrigation 2C Approx. Depth I I Eastern Surface Seal Installed by frul C ST 14.41 2 M F+ Repair Work Done U Type of Pump Lc�V ""4 H.P. ; I+ ' P State Work Done _ CA Well Destruction O Well Diameter 21% Sealing Material L Depth r/ Depth 2dlt Filler Material i Depth N I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is O available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soq to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. 8 Length of lines Total length/size Gr FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 Home owner or licensed agent's signature cenifles 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 cenifies 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 compsnsa-�' tion laws of California." The applicant must call for all required inspect a. Complete drawing on reverse side. Signed X M C . Ol-��`��„^"`'"� Title: <-A✓il C �c-�1 TLz-C `/ Date: ,, / (Z ( Z FOR DEPARTMENT USE ONLY / 'n Application Accepted by Date /[ G� J PZ Area Pit or Grout Inspection by Date �� Final Inspection by Date Additional Comments: �n•"/ G>;O 12 Applicant - Return all copies to: San Joaquin County Public Health Services �v Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95 1 S FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY fDATE J 9PERMIT N0. EH 13-26 I11EV.t i 51 fH 1 4•2646" !J 9 (? D lf/ !i"f2—