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I� APPLICATION FOR PERMIT SAN JOAQU IN COUNTY-PUBLIC HEALTH. SERVICES VA_�� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 a �ry Paid P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A ' (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a Permit to construct and/or install the work herein described. This application is made in coWliance with San.Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address.- . 1 t- 1� City LoJ1 Lot Size/Acreage ,i 1!(-,A ii q pf Owner's Name z `J Address S �t Phone ` Contractor Address License No. 12-7-6 A Phone 949 134 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ � �� W� THER ❑ Monitoring Well �! .p PUMP INSTALLATION�D SYSTEM REPAIR ❑ ya DISTANCE TO NEAREST: 960*fe-TANK SEWER LINES (9t5rP9SY0.t PROP. LINE t;O,) FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS It ❑ Industrial,, Ea Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing OQ 'f l Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing ecifi iidoo°s V] Public "" � �O1herIJ LL,kfl Delta - . `Depth of Grout Ci yp rutI I Irrigation j; �Approx. Depth t I Eastern Surface Seui Installed bO�5h,40 "Repair Work Done U . Type of Pump H.P. State Work Done — Well Destruction 0 Well Diametir rte—' Sealing Material i Depth i Depth __ i Piller Material i Depth TYPE OF.SEPTiC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 11 (No septic system permitted if public sewer is .i _. , . available within 200 feet.} Inilsllation'will serve: Residence_ Commercial Other Number of living units. Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. [71 ', 'l — Method of Disposal Distance to nearest: Well ,Foundation - Pr li r � operty Line i LEACHING LINE 0 No. 6'Length of lines _ - Total length/size Y k FILTER BED'; 0 -Distance to nearest: Well I Foundation Property•Lina c f SEEPAGE PITS I I Depth Size Number SUMPS I :Ll .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 1 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 subcontracting 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 lows of California." _ The applicant, t call for l requir inspections. Complete drawing on rave side. I 1 Signed _ — Title:. ¢ 5 ��-t....,,—, I l Date., F D ARTMENT USE ONLY Application Accepted byDate Are& Pit or Grout Inspection by Date Final Inspection by Data 3w�` 3 a i i. Additional Comments: S j u 3— t r -Applicant - Return all copies to: an Joaquin County Public Health Services - } Environmental Health Permit/Services 445 N San Joaquini ,P O Box 2008, Stkn, CA 95201- !: FEE ` INFO AMOUNT DUE + AMOUNT REMITTED C RECEIVED:BY. DATE PERMI7'NO. ryry t • EH%3-24 t11EV.11-%5, I EH ta•2e c � ar{� �� J ��' V