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APPLICATION FOR PERMIT 0 Lb SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Vf P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ZENIT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to Sass 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 41 Z: Z,CU J5g IK�171> City L=C�DI Lot Size/Acreage Owner's Name 7�L� Address _ Phone �a Contractor Addresstense N Phone 90 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ ky PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrisl ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing L) Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public ('I Other 0 Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx. Depth d Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth — - TYPE OF SEPTIC WORK: `NEW INSTALLATI(3N❑ REPAIR/ADDITION DESTRUCTION G iNo septic system permitted if public sewer Is ! , available within 200 feet.) Installation will serve: Residence Commercial— `Other Number of living units: _J_ Number of bedrooms_r ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK gC167_b Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,❑ ; ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well foundation Properly Line ? SEEPAGE PITS I I Depth Size Number SUMPS /r1VJEW X Distance to nearest: Well_ I Foundation; __ Property Line DISPOSAL PONDS O ` 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thework for which this permit is issued, I'shall not < employ any person in such manner as to become subject to workmen'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 compans tion laws of California." The applicant ust p if for all required ' pgct ns. Complete cawing on reverse side. a Signed Title: i _ Dater F DEPARTMENT USE ONLY`. a Application Accepted by Do r A as Pit or Grout inspection by Date Final Inspection.by . �-� Date Additional Comments; Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIO REALTH SERVICES R ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN,rP O BOX 2000, STUCKTON, CA 95201 ' INFO AMOUNT DUE ti AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT Np. . EH 13.24 I11tEV.I/14DI � 101803 ]—� + t— EH"44, sp- La t.C7� O