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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �� P O BOX 2009, STOCKTON, CA 95201 y �\ 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 Joaquin County Public Health Services. Job Address r Cdv'� L[�y% " — City riy, ,-, �L.ot Size/Acreage'.�/`jC X Owner's Name r l L 'C�r�� it1 C _ 1. f Address f" �l CL_�9` ['C��?ti� Phone Contractor Address �',� C. M, iCIL _`L . License No. Phone -SC TYPE OF WELL/PUMP! NEW WELL O WELL RE ACEMENT C i DESTRUCTION Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ 1- Monitoring WellS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS n D Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing '- XOomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 4��I Q— Specifications`4-IVZA `t f, `r i L-I I.1 Public f-1 Other n Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump --- H.P. Stale Work Done _ Well Destruction O Well Diameter + (,= Sealing Material i Depth ' Depth (f,r Filler Material i DepthZ �Ct YIA) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I 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 soil to a depth of 3 feet: .. 7 Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line PM YMIV4 LEACHING LINE C1No. 8 Length of lines Total length/size �I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sia r A Number SAN 10A � - ' �E 111 SUMPS LI Distance to nearest: W Foundation Pr UBS (tAL t �S DISPOSAL PONOS ❑ Property Line 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 oandi"the following: "I certify that in the performance of the work for which this permit is issued, 1 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 California." The applicant moust cc/all for MI required inspections. Complete drawing r> averse side. q Signed X �Cl ,�� Title: c' .-� Date: FOR DEPARTMENT USE ONLY /� I 9 Application Accepted by Data ( ` Area Ph or Grout Inspection by Date Final Inspection by yu� Dated �J Additional Comments: w- !'Yt Appl ant - Return all copies to: San Joaquin County Public Health Services ✓�� 445Environmental Health Permit/Services Lit 445 N San Joaquin, P O Boa 2009, Stkn, GA 95201 FEE INFO, AMOUNT DUE AMOUNT REMITTED J�CA(SH RECEIVED BY DATE PERMIT'NO. E;..2 atv.„4 sr ;CV /„/` U' -11 o" I 0-I `�