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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 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) - - r Application is hereby made to San Joaquin County for a permit to construct and/or install the trork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San fl,Joaquin County Public Health Services.r- : /[Job Address - �O H0/34 fZ"i! City 517�Jj Lot Size/Acreage 2 iKP-ES I Owner's Name / 1V Address S-7(001-440i3/A42X_ At Phone Contractor GA-9i�'�`� � Address 3-72Z W, t 1771 St- License No. C`AP Vo Phone TYPE OF WELUPUMP: - NEW'WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Gl 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -. 0 Industrial ❑ Open Bottom ❑ Manteca Dia-,of Well Excavation "" Dia. of Well Casing 17:1 Domestic/Private ❑ Gravel Pal ❑ TracyType of Casing_ V .Specifications ('1 Public 11 Other n Delta Depth of Grout Sear `Type of Grout f I I Irrigation Approx. Depth I I Eastern Surface Seal Installed'by t Repair Work Done L3 Type of Pump H.P. State Work Done Woo Destruction ❑ Well•Diarieter # Sealing Material & Depth Depth t 1 Filler Material,li Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I l DESTRUCTIO I INo septic system permitted if public sewer is ,"- I available within 200 feet.) Installation will serve: Residence_'r Commercial_ Other r Number of living units: NumbWof bedrooms Character of soli to a depth-of 3-feat: Water table depth SEPTIC TANK. ❑ Type/Mfg-"f"_` -----Capacity— No. Compartments PKG. TREATMENT PLT.❑ i Method of Disposal Distance to nearest: ell ~` Foundation Ptoperty.Lina 1 i LEACHING LINE 0 No. 6 Length of lines 4 �' Total length/size FILTER BED ❑ Moines to nearest: Well Foundation Property Line 1 , SEEPAGE PITS I I Depth Size Number SUMPS 1 U1 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 rubs 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, 1 shell not employ any person in such manner as to become subject to workman's wmpensation 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 compensa- tion laws of California." 1 5 The applicant must call for alt required inspections. Complete drawing on reverse side. �-Signed r ¢ Title: Date: �� R DEPARTMENT USE ONLY ApplicaWn Accepted by9 ate Area Pk or Grout Inspection b Date Find In F44 htvc- w a.�... �.�- ceWc Y spectbn by Di �,`_! d roti Additional Comments: L.• 4.P � ( ke r ♦a -_ 'Applicant —Return ell-copies°to: San Joaquin County 'Public'Heai`th Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Sox-2009, Stkn, CA 95201 I I IEEENF) AMOUNT DUE AMOU REMITTED R RECEIVED BV DATE-,, PERM17 N0, EH 13.14 IREV.rie6! EH 11.1E