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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .-31Q ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PER_MIT_ E%P I RE S 1 YEAR FROM DATE I S QED (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ceal�liance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address C) City Lot Size/Acreage Owner's Name "4LK Address dlfgS"_Z, 4.,_ g t r/.Phone Contractor P !' Address� ��a �•20-Q . 4121— License No/k2 _ ' Phone ) TYPE OF WELL/PUMP: NEW WELL ❑• WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 15- PUMP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public 1:1 Other FI Delta Depth of Grout Seal Type of Grout I+l'lrrigalion _.Appros. Depth I I Eastern urface Seal Installed by C� Repair Work Done ❑' Type of Pump _ A H.P. 1 Q State Work Done Well Destruction M ❑ Well Diameter Sealing Material i Depth _ _ Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other }R Number of living units: Number of bedrooms Character of sola to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Q Method of Disposal E Distance to nearest: Well Foundation Property Line r'p LEACHING LINE Ll No. & Length of lines Total length/size t/) FILTER BED ❑ Distance to nearest: Well Foundation Property Line'J SEEPAGE PITS I"I - Depth _ _ — Si- "" Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 11 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 comity 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 persona subject to workman's companss- tion laws of)California." The applica nt call fo a required inspections. Complete drawing onreverseside. [3 Signed It_ _ Title: U!�� Date: -3r^ .2- z3 F R.DEPARTMENT USE ONLY 4 = Application Accepted by Date 14MA - Area Q Pit or Grout Inspection by Date Final Inspection by Data S- Addhionsl Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO CASH AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH S]•24 IltttV.4/J1 5i iJ till 1�.� ✓ (l(/