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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �O ^ ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 K0D (209) 468--3447 PERMIT EXPIRES I_, YEAR tAO,M„DATE ISSUED (Complete in Triplicate) t 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. /lob Address 1:16-S krzoa"{A � City Qu CKC Lot Size/Acreage -IT X / t l ZS Owner`s Name LP_'QCSJ7.?... h res ddress _` � eau)�� Phone AA2`Z-'4 S Z Contractor GrMIG��?J l��s pttL� Address License No, Phone PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLO. l PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications f M Public f;1 Other t ❑ Delta Depth of Grout Seal Type of Grout M Irrigation —.Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done L] Type ollPump 1 H.P. State Work Done_ �J Well Destruction ❑ Welt Diameter Sealing Material i Depth Depth Filler 1( TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AOOITI N C.: E R C 0 o septic system permitted if public sewer is V� Installation will server Residence^ Commorclaf_ Other Permit may hav a}{@ii ¢lst�gt�j,rK�QQl,f V . Number of living units: Number of bedrooms work being completed or inspected Character of soil to a depth of 3 feet: f r- �..: 81t, MA&Fv \ SEPTIC TANK ❑ Type/Mfg UY Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE C1 No. & Lengthof lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I1 Sire Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . ❑ ` 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 Sen 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 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 eompensa- tlon laws of California." ,The applicant at call for R req it inspgctlons. Com late drawing on r eras sideIA Signed Title: Date: — FO DEPARTMENT USE ONLY i Application Accepted by AData u��:AQ Area Pit or Grout Inspection by r Date Final Inspection by t Date Additional Comments: t` I Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION-PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009; STOCKTON, CA 95201FEE 1 INFO AMOUNT DUE J,4MOUNT REWT-TED CA.';W RECEIVED BY DATE PERMIT'NO. EH` EH 1 !•26IREV,iin5151 1