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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTU+ VICES ��,r r, , ENVIRONMENTAL HEALTH D I V I�j r' 445 N SAN JOAQUIN, PHONE (2019 420 P 0 BOX 2009, STOCKTON, CA �4 i PERMIT EXPIRES 1 YEAR FROM IJAEAG (Complete in Triplic te� 11 Application is hereby made to San Joaquin County for a permit to construct an irate e 1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulea an Joaquin County Public Health Services. Job Address I �� I P ,.Yl l.-r!1_rtc - City �e1_n�_ ,C�t_..,Lot Size/Acreage Owner's Name �r"k d-,4,A_1,:il AddressR F.� '� '� ��-" - Phone Contractor , I Address 2 Q2 c_) C M%,I iii' �� License No. l 1 X Phone TYPE OF WELL/PUMP: NEW WELL ❑I.nt,'ltc(iA)WELL REPLACEMENT DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O+v;, Monitoring Ye115 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 r > Industrial ❑ Open Bottom\Manteca Dia. of Well Excavation It�' Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing rZC, >1 SIL' Specifications L 0 f( L I cfi I'1 Public (71 Other (l Delta Depth of Grout Seal ~ Type of Grout ,?n LF I I Irrigation IS;a"f2'Appfoz. Depth I I Eastern Surface Soul Installed by ?�e<,-ry i v ) �n Repair Work Done U Type of Pump H.P. State Work Dons _ \ Wait Destruction O Well Diameter Sealing Material L Depth Depth Tiller Material 4 Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms v Character of soA to a depth of 3 feet: k 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 Cl No. f5 Length of lines Total length/size FILTER BED O Distance to nearest. Wall ndation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: NI Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 must call!9L,an required inspections. Complete drawing on reverse side. Spred x � Title: 'C � mw-` `� Date: - FORDEPARTMENT USE ONLY Application Accepted byDat. PAYMENT CEIVED p 3 Ph or Grout Inspection by Date Final Inspection by C R�yje Additional Comments: -{ _31 j .lq SS E y3 SAN JO Q _ Applicant - Return all copies to: San Joaquin County Public Health Services PUBLIC HEALTH SERV{CES C Environmental Health Permit/Services 7 J 445 N San Joaquin, P 0 Box 2009, Stkn, CA 900RONMENTAL HEALTHDIVISIO FEE AMOUNT DUE AMOUNT REMITTEDSN RECEIVED BY DATE PERMIT'NO. 1 17 . EM14-24IIIfV.ii"5r �` , U Eq 14•I6 !