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APPLICATION FOR PERMIT . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9520 . (209) 4683447 PERMIT EXPIRES 1 YEAR PPATH 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 la made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address _ 5 /0 ,y t A?22//V -CT _ ___ ____ --- - - City_&�/ _X_clfLot Size/Acreage /9Coe,E'f Owner's Nam* 90 kd L S,000 Address 3/0 /v. A7 A/2V - /'7�w?��-�_ Phone D O Al a is p5 r"0 51;7 !eD C.09 I / Contractor S°NS Address F6zP License No. SbIS4 G Phone TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACEMENT Q DESTRUCTIO t of Service Well ❑ PUMP INSTALLATION C) SYSTEM REPAIR OTHER$ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CON TR CTION SPECIFICATIONS f7 Industrial ❑ Open Bottom 0 Manteca Dia, 0 ell Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracy Typ of *sing Specifications M Public is Other ❑ Delta pth of rout Seal Type of Grout 0 irrigation —,Approx. Depth d Eastern Surface So I Installed by Repair Work Done 0 Type of Pump N.P. State Work Done_. Well Destruction 1) Well Diameter Ing Material ith Depth i11er Material i Deh O TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 leel.l Installation will serve: Residence.r_. Commercial Other Number of living unite Number of bedrooms Character of#oil to a depth of 3 feet: Water table depth SEPTIC TANK O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ A Method of Disposal P Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size V FILTER BEA 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 ms call for all required inspections. Complete drawing on reverse side. Signed Title: 1L�s!'^��1 _...._,._,_ Date: _/(y�3 A FOR DEPARTMENT USE ONLY Application Accepted byzteDate U Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 FEE INFO NT DUE AMOUNT REMITTEp CASH RECEIVED BY DATE PERMIT'NO. ti EN 13.241 REV.Iinsl e EM 14.2e