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f'Vv 74,• g5 411TAPPLICATION FOR PERMITI 1 f $5 Ra? 511 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � GYa � la2p 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ! o5 djq PERMIT EXP I RES I YEAR FROM D TE SJED (Complete in Triplicate) I Ayplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This syplicatioa is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. j Job Address r��.� �Z +� , City I _ r /O? Lli 1 Lot u �^ J Owner's Name t"e 1A L a-se ,X 6Q i"/VAddress rn.�-_11� L-161S< /rn,� � 4?CI—Phone Contractor -� FL�[lN �OCAddress/r/q / License NO � Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I J DISPOSAL FLD. PROP. LINE FOUNDATION Js i AGRICULTURE WELL ��GOTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation pia. of Well Casing Z:V. omestic/Private 09LOravel Pack 0 Tracy Type of Casing �`� �_ Specifications 1'I Public 1:3 Other it Delta Depth of Grout Seal �© Ty�of Grout I I Irrigation -3:29-.Approx. Depth I I Eastern Surface Seal Installed by .lel e l>£ ��[�/II«Q' _ 9n. Repair Work Done L) Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ak Depth r- Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION E I (No septic system permitted if public sewer is available within 200 test.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of sols to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Cortmslt PKG. TREATMENT PLT, C7 Method -Di ENT Distance to nearest: Well Foundation Property LineD LEACHING LINE ❑ No. & Length of lines Total length/sizeQ A p I IR A Pk FILTER SED C7 Distance to nearedu : Well Foundation PraparRL4Wr r SERVICES SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i --:4 Woraby 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must tail for sitt req 'ad ad ln";tions. Complete drawing on reverse side. c� Signed X tI e'-6 Title: L 0tL/4?n „ . ,.._ .,_ Date: 3 DEPARTMENT USE ONLY _ Application Accepted by 09;FOR Date /� y Area ,J- Pit or Grout Inspection by Date Final Inspection by ut Date # Additional Comments: - A GDSI i Applicant - Retu n 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 AMOUNT DUE AMOUNT REMITTED K RE EIVED BY DA E PERMIT'NO. INFO CASH ` EN M24(REV.hots)Nk, EN u•ie // CCV1J �J� j