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APPLICATION FOUR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made to San'Joaquin County for a permit to construct and/or install the work: herein described.r This + application is made in coni�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7 ��,T/ Ll � City __11 Lot Size/Acreage Owner's s1�.,LT6f,"A'Uce AddressS90 Z AV W';6 034 OPV Phone �� 6 Contractor ®W 1J2 Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST. SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION? - AGRICULTURE WELL OTHER WELL PITS/SUMPS .T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Peek i t ❑ Tracy Type of Casing_ { Specifications ^I I"I Public F1 Other I n Delta Depth of Grout Seat Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump I H.P. T " Stale Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth p Depth I Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is a available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms 3 Character of soil to a depth of 3 feet: - - 'Water table depth SEPTIC TANK A Type/Mfg _' _ - apacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: We11_�� foundationProperty Line /:2,!5-/ .f ) ` 5 f LEACHING LINE J4 No. A Length of lines Total length/size D f t FILTER HED C1 Distance to nearest: Well.&_X-Foundation D ?� Property Line�1A F-> f^ SEEPAGE PITS Depth - �.��r- Sise Number_ - �-22 SUMPS LI Distance to nearest: r Well Foundation Property Line DISPOSAL PONDS ❑ 4 \� 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 csnifies the following: "I certify that in the performance of the work for which thispermit 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 F 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 m at call for all r tired inspections. Complete drawing on reverse side. a Title: Z. f _ Date: t f R DEPARTMENT USE ONLY `} G Appli lionAccepted by Date +^ �� Area o.), 1 2 Grout Inspection b Date Final Inspection b Date LL� 3 Additional Comments: rTr i Applicant - Return all copies to: San Joaquin County Public Health Services ! ]environmental Health Permit/Services 4-445-N..Sanr.Joaqui.n,-.P-O-Boa--2009.,.,Stkn, CA-95201--FEE i INFO AMOUNT DUE' AMOUNT REMITTED CASH RRECEIVED BY DATt 4PERMITNO, • EH 13.24 IREV."... S dr V t�fl ...-r LSJ "'" �..1 y �� }