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z APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sae Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. p� _�t, We,115 L t<Ar�ylr� _- _-- Lot Size/Acreage Job Address 1n', �/}�y� City 4 Owner's Na,,Pa Q-) T 1�CJLi�l--Tea6iAddress Phone : 01 Eontfacttp LL �" — Add t/ rrse No. Phone L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Neil ❑ PUMP INSTALL.ATiO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 C7 i ustrW ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications \� 1.3 Public EI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx, De I I istern Surface Seal Inslailed by A 1, Repair Work Done ❑ Type of Pump H.P. State Work D u� Weil Destruction ❑ Well Di t r Sealing Material i Depth . - [� Depth '� filler Material i Depth (\/ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �\ within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 fat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal k Distance to nearest: Well .Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines F`; Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPA43E PITS 11 Depth Size r Number ' SUMPS Ll Distance to nearest: Weil Foundation -= - Property Line DISPOSAL PONDS ❑ 1 hereby cenify 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 Ar Homs 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 follovAng: "I certify that in the pedormince of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of nia." The applic m t call f ins tionr. Complete drawing on revs sid S' Title: - Date: 14 W 0 DEPARTMENT USE ONLY Application Accepted by00f_AaDate 1 R 2(,J` Area _122— Pit or Grout Inspection by Data Final Inspection by y l,/AL1 Data 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY t DATE PERR�MIT'NO. . EH 13-24(Iffy.1 i N 51 IO D EM 14-M ,`