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APPLICATION FOR PERMIT SAN __AQUIN COUNTY PUBLIC HEALTH 6--VICES ENVIRONMENTAL HEALTH DIVISION J .`30; 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT FIRES 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 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 Servicers. n Job Address l q3 44i �!/�Af /gyp City Lot Size/Acreage Owner's Name _ ✓ 5�1 Cc//Jrt�y Address Phone Contractor Address l?� �)U iG .g �2p� License Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I"1 Public Cl Other n Delta Depth of Grout Seal Type of Grout 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 Well Diameter Sealing Material A Depth Depth Filler Material i Depth t/v TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Z Other Number of living units: Number of bedr000m$- Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg PW A, capacityZj�— No. Compartments PKG. TREATMENT PLT. O % fir— /� Method of Disposal Distance to nearest: Well 5Z r Foundation Property Line ,�-7 LEACHING LINE D No. b Length of lines —e*o —r— Total length/size �clLTc/ r" FILTER BED ❑ Distance to nearest: Well 40,J tF` Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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: "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 must call for#I rreeqquusred inspections. Complete drawing on r arse / Signed X_ - 1 _ �� Title: et7_ , Date: a- FOR DEPARTMENT USE ONLY Application Accepted byA A64 A&AA, Date C�' /jZ� Area L OP��.G ut Ins 1110 by Date 3 �� L Final Inspection bye/�/ G!^- i,� Date C7! Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE PT�REMITTED CASH CK RECEIVED BY DATTE�j PERMIT N0. FEE EM 17-II t11EV.r i w si ( I t!- t7 /�U /�' i 32- 4-20EH c�.7a �/1 V t �—