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{ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PMLIC HEALTH SERVICES EYV'IRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 [ BERMIT EXPIRESFROM 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 t application is made in ccuplisnce with 34n Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 37 � �r��r 3�-' �<-�+�r C City Lot Size/Acreage 0, ; ._ I i j LOwner's Nae r1 o G:� mAddress S—4 e- 40:24�. rZ,v1*r% ,G A 9(/S'i: ? Phone Z 7 7- t t ! 81l H•..,,;I t�.. { Contractor ��-�+ Ir.,.� r:11 , rna Address Mss I r',c�,krCA yyeLy License�Ko. -?7i0t1L.S•Z Phone ;fl :Zt-2.9a TYPE OF WELL/PUMP: NEW WELL)K WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ j L PUMP INSTALLATION C3SYSTEM REPAIR ❑ OTHER C3 Monitoring Well b� I _ J't DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES S 0 DISPOSAL FLD. PROP. LINE Lt)4 FOUNDATION AGRICULTURE WELL OTHER WELL-2-0f&- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom C3 Manteca Dla. 01 well Excavation Dia. of.Well Cas+^g [, L I"1 Domestic/Private 14 Gravel Pack ;7 Tracy Typo of Casing S&�.�- ..Ic +0 Specifications Il Public I'1 Other n Delta Depth of Grout Seal Type of Grour do I I Irrigation L'—Approx. Depth j I Eastern Surfaes Sent Installed by Pour �ro... Sur��e e 1 Repair Work Done ❑ Type of Pump H.P. Slate Work Done Z ? WeM Destruction ❑ Welt piemetar Sealing Material i Depth L tiller ller Material i Depth Dep 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 fait.) t InstsUtion win saws: Residence_ Corrwnercial— Other Nurnber of Oviog units: Number of bedrooms Character of will to a depth of 1 feet: Water table depth y� LEPTIC TANK O Type/Mfg Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of Dispoisl Distance to nearest: Wen Foundation Property Lina LEACHING LINE ® No. & Length of ram Total length/sire L 4 Foundation L+M FILTER BED D Distance to nearest: Welt Pr oparty t SEEPAt3E PITS I I Depth Sire Number SUMPS S LlDistance to resrest• WoY Foundation Property Lina DISPOSAL PONDS ❑ } I hereby certify that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lays, and rules and regulations of the San Joaquin County 1, owner or licensed nt's tura certifies tits following: "I certify that in the performance of the work for which this permit is issued. I shall not Horne o +W t+9^a employ env parson in such rmnrw as to become subject to workman's compensation Iowa of California." Contractor's hiring or sub-contracting signature Lcertifies ttw following: "I certify that in the performance of the work for which this permit is issued,1 shalt employ persons subject to workman's contpensa a tion laws of California:" J The applicant must cad for all required ions. Complom drawing on reverse lids.— Sea Squad Yy✓ Tads: Ser+to r d r w i; Dste: Il 2 j FOR DEPARTMENT USE ONLY �/ Application Accepted by Date Area d 7 LPh or Grout Inspection by rT�'r` Daee -� Final Inspection by Date.--� '1 'Adrtiorwd Commsrrts: Jff b r7 �i 3 !/M aL�J rcJ A r" Applicant - Return all copies to: San Joaquin County public Health Services L Environmental Health Permit/Services 445 N San Joaquin. P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEAMFI-NO. 1NF0 CAS .L M24 rrtty.treat ec" 31 f 306 1 ff