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' 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 EMRES 1 YEAR FROM DATE j_§SUED (Complete in Triplicate) Application is hereby made to Sera 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 Lad Regulations of San Jaequin County Public Health Services ILL ti /x / Job Addr �}ess `�O 0 CitySWI:km Lot Size/Acreage '--3 f0 /Q ' Owner s Name - C Address 7` 01 f.07, /br"t✓-Lt Alizor .t/1 PhonL O)(13-�1 Ca �. rLYI�.�'f . Contractor dress2_0625E,_ �� .504A'License No EjZ22ra -8712- ' TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑Z-43 Out of Service 11011 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �3 CMpttitoril bell ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES > 5066 DISPOSAL FLD l��,/-,�� PROP LINE � FOUNDATION ZD t AGRICULTURE WELL �^ OTHER WELL�SL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ !Manteca Dia of VOW Excavation Dia of Well Casing [-I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I I Public n Other ( /� t-1 Delta Depth of Grout Seal T pe of Grout I I Irrmollon V-Approx Depth! I I Eastern Surface Seal installed by Repair Work Done L1 Type of Pump H P State ark Done _ Well Destruction ❑ Won Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION 1 I REPAIR/ADDITION i I DESTRUCTION i I INo septic system permitted if public sewer a available within 200 feet I installation will serve Residence.....r, Commercial Other Number of living units Number of bedrooms Character of soil to a depth of 3 feet Water table depth ' SEPTIC TANK © Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest- Wall Foundation Property Line LEACHING LINE 0 No & Length of lines Total length/sue FILTER BED ❑ Distance to nearest. Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared thea 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 esrufies the following "I certify that in the performance of the work for which this permit az 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 'candies the following -1 cartrty,that in the pedomtance of the work for which this permit is issued, I shall employ persons subject to workman s compensa tion laws of Cafrforrds.. The nt twig fo u mapactions Complete drawing on reverse side Signed Title /�/ Date sh4A�� FOR DEPARTMENT USE ONLY Application Accepted by Date Area Ph or Grout Inspection by Date Final Inspection by Date ddhional Comments Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 K San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERM17 NO E124 fnfY �i�stl EH 14 38