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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 FIRES I YEAR FROM DATE 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 Is made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County public Health Services. �? .lob Address _ Z y6, -7 � �t �h 0��htrE' �'�,- City r`-`�© ""� _. Lot Size/Acreage � �t � 2- Owner's NameAddress Phone Contractor 5#013fFnd C(7-5-i:Address /3(—] CII-AWf1J(zb 0� Licen o. 9- h s Z� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC -❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ., I'l Public la Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth 4 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 6*lrDESTRUCTIONPq INo septic system permitted it public sewer is available within 200 feet.) � Installation will serve: Residence_X Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg ELZA ftq t6idIfS Capacity No. Compartments PKG. TREATMENT PLT.❑ _ Method at Disposal ista�nca to newest: Wel4 ounda n Property Line ~ LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Weil. Foundation Property Line DISPOSAL PONDS ❑ 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 env person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 at alljo all required inspections. Complete drawing on reverse side. Signed ` Title: C --Tcr��, Date: t l` -7 ` _— ORNT USE ONLY Application Accepted by Date ren 0-LI Pit or Grout Inspection by Date Final Inspection Date' Additional 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 CK i- INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' EMN 13-24 1ttEv.r,r s, � � Lt1 q�oa s �_ 914-26 Z