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wor, 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /033 44F;V5i' -<'611)77-f /9Gz City��i'Cx7o.✓ Lot Size/Acreage 1,5- 1-..2 Y -.3-7 Owner's Name -5-*AI Z4 r'� eed;/i�r Address Phone Contractor Address G7 ZzcX /CFS/ License No.,1':$�/gV Phone .77-Y-1" TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION o Out of service well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A A CONSTRUCT)ON SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of W Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack O Tracy Type o asing Specifications I'1 Public Cl Other fl Delta ep of Grout Seal Type of Grout Irrigation —Approx. Depth I I Eastern ace Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Weft Destruction O Well Diameter Malel i Depth Depth Tiller Mater, i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE IR/ADOITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ that Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments �y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 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 O 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 certifies 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 taws of California." Contractor's hiring or sub-contracting signature certifies the foNowing: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must for all requirso in tions. Complete drawing on reverse side. Spm Title: , j4-,l /`fil f r�.1�i Date: O , FOR DEPARTMENT USE ONLY Application Accepted by [� �^��'jJ`� Data /2- 8 �' Area 11 Pit or Grout Inspection by C" `^^""`` Date Z 2-_ Final Inspection by � Data �?Z9 Additional Comments: Applicant - Return all copies to: 9 Joaquin County Public Health Services / Environmental Health Permit/Services p 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKS CASH RECEIVED BY DATE PERMIT'N0. )NFO Q� �/ p . EN 112.INEV.r/4 St � l 2,z.(. 1 4L r/ /e Q Z �a�3 0 EN 11.76 ((JJ