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t APPLICATION FOR PERM I T f 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 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Service . ,-�O/VV 0 C. 1 �4SS g f•J . Job Address 'F 3L 5e g o of.4 City Tr,-*C 4 Lot Size/Acreage Owner's Name PlGee Address 3OJ 000 1f^F5D/V K./- Phone Contractor 4 pw ,-tz Sla v Address 4�'T OL U e v-*'7 A4-' License No.YYL W,1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O 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 O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications tz (I Public Cl Other fl Delta Depth of Grout Seal Type of Grout OO I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O WON Diameter Sealing Material i Depth r Depth Filler Material A Depth 1\ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION A DESTRUCTION I I (No septic system permitted if public sewer is V) available within 200 feet.) V) Installation will serve: Residence Commercial_ Other A Number of living units: _ I Number of bedrooms f Character of soil to a depth of 3 feet: _Acla L Water table depth A0 � SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED O Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth 13 K /3 1C 3 Number SUMPS IK Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O CffA'XtZtR.3 24cJrQ¢Z.t' I hereby certify that I have prepared this application and that the work will b 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, 1 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 compensa- tion laws of California." The applicant mu t all for all required inspections. Complete drawing on reverse side. Signed X A Title: Date: g f L V , FOR DEPARTMENT USE ONLY Application Accepted by � Date Z 17— Area �b6 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,,R O Box 2009, Stkn, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMITN0. . EH 13.24(REV.I/M si Z)11� jay_o-C) !l 5� 06 /.sVD ?2E Lq2- §z 2- EH 11.2a _Z_