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yy APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON1lENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;J (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the vork herein described. This application is made in catiliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicei. . /n( it r2(� 0 City.e--- hot Size/Acreage Job Address I L..At IJQ�J1�Gt1 �-�� Address 4bi4_VV\e �f 52�� Phone Com'-13.'.3 Owner's Name i. zm VvhO.c�T -�� I Contractor 0 " Address- �* "z t : License No. ��3{'E�l 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17-1DESTRUCTIONCi Out of Service Well PUMP INSTALLATION P--- SYSTEMREP ❑ I AIR 13OTIHER ❑ 14onitoring well L] � I DISTANCE TO NEAREST: SEPTIC'TANK L SEWER LINES DISPOSAL FLO. ? PROP. LINE FOUNDATIONfi. AGRICULTURE WELL OTHER WELL " PITS/SUMPS .� INTENDED USE TYPE-OF WELL: PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ,' j .;` j. ❑ Open Bottom' ❑ Manteca' Dia. of Well Excavation Dia. of Well Casing " p1rolmestielPrivate ❑ Gravel Pack 1 0 Tracy,----Type of Casing_ specifications ' I1 Public I-IOther u' t. ❑rDelia- r Depth of Grout Seal Type of Grout I I i Irrigation Approx. Depth I I Eastern Surface-Soul Installed by Repair Work Done 0 Type of Pump ) H.P. State Work Done t !A I Wali Destruction ❑ Wefl Diameter I Sealing Material 4 Depth 1 CSR +Q- al ! hiller Material i Depth ] t 01 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other , ! Number of living units: Number of bedrooms Ip Character of soft to a depth of 3 feet: Water table depth {j SEPTIC TANK ❑ Typel.Mfg Capacity No. Compartments k1 * { ` Method of Disposal PKG. TREATMENT PLT.X11 r. !_ _ r.._ . Distance to nearest: Well Foundation Property LineJ. ) s 1 LEACHING LINE ❑ No. b.Length of lines Total length/size t �, FILTER BED ❑ Distance to insarest. Wail Foundation Property Line' I SEEPAGE PITS I I Depth r Size Number € SUMPS Ll Distance to'r"rest: well Foundation Property Line DISPOSAL PONDS ❑ r ` 't I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and I rubs 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 shell not employ any person in such manner as to become subject to workmen's compensation laws of Californis." Contractor's hiring or sub-contracting signature ,I certitioe 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?' I The applicant must coil for all required ins coons. Complete drawing onreaid Sigi Title: } Date: i ` !� F R DEPARTMENT USE ONLY ! �_ Application Accepted by Date. ' 1g Area 02 Pit or Grout Inspection by Date Final Inspection by w Data 3 3, i Additional Comments: f Applicant - Return all copies-'to: San Joaquin County-Public Health Services m{ Environmental Health Permit/Services 445 N San Joaquin, R0 Box 2009, Stkn, CA 95201 {. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i INFO i ' . EN 13.14 UtEV.F i HSI Yc(} EH 14-291 {