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e APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH 8E*S/ , ENVIRONMENTAL HEALTH DIVISI N 445 N SAN JOAQUIN, PHONE (209)4 , P 0 BOX 2009, STOCKTON, CA 95 � � FAC # - TTTI\!TT TOTIT TI TICS 7 [TTATI '01"/ Zr T\TT1 [[1TTTTT (Complete in Triplicate) INV ## 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 Services. 1,1A �/L 1 / I A (? a . � �• 491L eKiA/ot Owner's Name � CK If CASH Address / moo' 41OX ifA Phone DATE PERMIT NO. 324r F,Afc. U Air, .l>k2 4-f L4 -2032 Contractor&,- Address Q.s_CA'a TIM 2- License No. Le_ PhonikT1r-8•_2-945¢ TYPE OF WELL/PUMP: NEW WELL t9 WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �-S�' SEWER LINES ? DISPOSAL FLD. >1 PROP. LINE FOUNDATION d r AGRICULTURE WELL ? j `" OTHER WELL,y fa S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial O Open Bottom ❑Manteca Dia. of Well Excavation —Dia. of Well Casing 2 �r U Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications 5 40 I'1 Public KOther n Delta Depth of Grout Seal Type of Grout to C.w-I't I I Irrigation � 'Approx. Depth I I Eastern Surface Seal Installed by + r Repair Work Done U Type of Pump H. P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soA to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of i al Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line f iNVINO NTAI HEALTH SEEPAGE PITS 11 Depth Size Number �?I W M i' iV V 1 LES SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 callforall regulired iins%ctions. Complete drawing o/n/reverse side. �[ Signed c �s..�( �. �.cC (c✓ Title: HrS.Ci•yu�it f fT Date: FOR DEPARTMENT USE ONLY ��/ / Application Accepted by Date % Area /y Pit or Grout Inspection by ;Z - Applicant Y Q Final Inspection by Z Q7 Additional Comments: T Applicant - Return all copies to I , / C'- 71 L . EN 13-24 IIIEV. EH 14-2E San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 SR 0 0 0 �� lupi FEE AMOUNT DUE AMOUNT REMITTED CK If CASH RECEIVED BY I DATE PERMIT NO. 3DU