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s t1 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 PERM T EXPIRES 1 YEAR FR lIt DATE ISSUED :.I (Complete in Triplicate) Application is hereby made to Elan Joaquin County.for a permit to construct and/or install the work herein described. .This application is made in compllance with San Joaquin County'Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicers. Job Address City �� Lot size/Acreage Owner's Name Address /`��ZQ Phone S 3 3 Contractor Address License No.�l1/ _Phone TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT 17.1 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR D OTT ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.,/t� PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rf t El Industrial 0 Open Bottom El Manteca Dia. of Well Excavation PaDia. of Well Casing Domestic/Private Gravel Pack Tracy Type of Casing__ - 6LC�= - Specifications f") Public /171 Other 0 Delta Depth of Grout Seal Type of Grout I I Irrigation ____Approx Depth I I Eastern Surface Seal Installed by r H.P. State Work Hone Repair Work Done U Type of Pump Well Destruction ❑ Well Diameter Sealing Material i Depth ' Depth biller Material 4 Depth "►�� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Q r available within 200 feet.) Instalkatinn will serve: Residence Commercial_ Other NumbRr of living units. Number of bedrooms ' Character of soq to a depth.of 3 feet:) w r t SEPTIC TANK ❑ Type/Mfq Capacity Nr��,�+ nCts PKG. TREATMENT PLY{LlMgt rBUF Distance to nearest: Well Foundation Propenyf�t.�r_ 1 LvJ�G.��++ JOAQUIN �kj LEACHING LINE 0 No. a LeAgth of lines Total lengtph FILTER BED 0 Distance to nearest: Well FoundationQ{�} �k�t�l�+al0 SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑,�: - _._ 4, _ _ -. P = _ .�_:. ;• I hereby comity 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 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."Contrictor's hiring or subcontracting signature Y certifies the roMo 'ng:•I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion!a Cal ornia." I J The applic at wit for all raquir pgctions. Complete drawing on ergo sjde. Signed X Title: Date: ` °�✓' ,,FOR DEPART NT USE ONLY r Application Accepted by V Date b Arae t� Pit or Grout Inspection by Date Final Inspection by Dete rG Additional Comments: 1-14 7 q `"'1 y j 6,jeem,-7—---91 /0-6 -- I Applicant - Return all copies to: San Joaquin County Public Health Services Env445 N Santo health Permit/Services r - 445 N San Joaquin, P 0 Box 2009, Stkn, DA 95201.: FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMiT'N0. INFO l �-v� $t-o-zJ � � f- . EM 132�.IREV.tina� (� eN 14.25 r.