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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTALfHEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O�BOX 2009, STOCKTON, CA 95201 A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) -z - Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. YJobAddress 2 City,122,j1r CeCc71ot Size/Acrersge — CYt� -_ y� 1 ? I-e 4 /\Owner's Name _ J, Address _ Phone FZA� 1 contractor "� Address_ Ya � •�-- -- License No. Phone TYPE OF WELL/PUMPV NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 1 OTHER El Monitoring Well Cl ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS`. y r n Industrial ❑ Open Bottom ❑ Manteca Dia. of Walk Excavation Dia. of Well Casing F.1 Domestic/private Cl Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public (-1 Other Cl Delta 'Depth of Grout Seal Type of Grout I I Inigation, —Approxi Depth I 1 Eastern Surface Sell Installed by Repair Work Done 0 Type of Pump H.P. Stats Work Done Well Destruction 0 Well Diameter Sealing Material ale Depth. Depth biller Material A Depth ¢_ _ TYPE OF SEPTIC WORK:. NEW INSTALLATION REPAIRIADDITION # I DESTRUCTION I I INo septic system permitted if public seweil %-• • available within 200 feet.) t l� I Installation will serve: Residence Commercial X Other Number of living units: Number of bedrooms4'! M Character of soR to•depth of 3 feet:,' Water table depth " SEPTIC TANK .. M Type/Mfg CapacityN.2--Q 7- - No. Compartments 7- PKG. TREATMENT PLT.Q f i Method of Disposal UE N ,. tZ Distance to nearest: W II _ Foundation�-Property Line 'b r ` C LEACHING LINE. � m Length of linesTqtal length/size FILTER BED 0 Distance to nearest. t • ~Foundation ta�0 1 Property Line 2-V 0 SEEPAGE PITS kDpth Siza Number SUMPS Ll DivairwDivan to rtaanst: I Foundation Property Line Z-0c, DISPOSAL PONDS D ` hoc eu5,o - .sf%i c� `_ I hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin county Ainances, state laws, and rules and regulations of the San Joaquin County r 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 sub-contracting signature certifies the following:.'1 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 must all for elf requir ions. Complete drawing on (ever side. Signed Title: —i / /-1'11�� -- Date: ��-/ -» 92, F R DEPARTMENT USI( ONLY 1 Application Accepted by Date Area QZ- I Pit or Grout Inspection by Date Final Inspection b Dote I Additional Comments. •--,—••- - .-------- --- R Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/8ervices 445 N San Joaquin, P O Box 2009, Stkn, CA 95201. 4 IF 0 AMOUNT DUE AMOUNT REMtTTEO CASH CK if RECEIVED BY CATE PERMIT NO. . FM 13.2i 111EV.F A t51 N7/I L ,C f�� e o C� .33L71 111J9-?2, 1`12--_37 5 EH u•1e L