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} APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCHTON, CA 95201 (209) 468--3447 (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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �1MJ 410"a-141 f'1QSNl nr� 4Y e. City 511 oc�c"I ury Lot Size/Acreage di �� QCT it Fc o1✓ �erII u1'A 23to c1,1y,-eiV 2A_ a_Vy o,Qo C� le 246 2C k Owner's Nome Address - f'� Phone k YICf//�!/�,` dIr LL '��rLr ��[�9 LF}c/�/i✓/ L/fl. �f'` ' License Na T92 390 Phane�✓10 Conlraclor K /'Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 . PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 �j �ell DISTANCE TO NEAREST: SEPTIC TAIK SEWER LINES Fr DISPOSAL FLO. '� PROP. LINE 2 F?: FOUNDATII N LO 14:r AGRICULTURE WELL OTHER WELL �o �j PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation 1,L Lor Dia. of Well Casing U Domestic/Private 0 Gravel Peck 0 Tracy Type of Casing G Specifications 411 M Public Other it J9 Delta Depth of Grout Seal Q Type of GroutC�� u _ 4f�J3 r�� its E/.tFLriaJr-i GI t iga��tion +�T SD.ApproK. Depth ❑ Eauern � Surtace So-al Insialled bye_ F Repair Work2ol U Type of Pump H.P. State Work Done_ Well Destruction D Well Dismeter Sealing Material i Depth {+ Depth } Filler Material i Depth ^� { TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION 0 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�� Commercial Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth Ip SEPTIC TANK ❑ Type/Mfg I Capacity No, Compartments PKG. TREATMENT PLT, 0 {+ t Method of Disposal Distance to nearest: Well Foundation Property Line l� I LEACHING LINE 0 No. & Length of lines Total length/size I FILTER BED Cl Distanceto nearest: Weil Foundation Property Line i SEEPAGE PITS 11 Depth '`) Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ :1 ' 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 t _ Home owner or licensed agent's signature certifies the followings"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 Cahlornia." Contractor's hiring or sub-contracting signature i 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 compansa• t tion laws of California." `1 The applicant must al required inspections. Complete drawing on reverse side. � r S Signed Title: � Date: l7- 7,4^l� t?3.3 ? FOR DEPARTMENT USE ONLY { ' C f Application Accepted by _ AV Date 3h ` Area T5 r t 01-P Pit or Grout Inspection by dVA1_""t Date 4S final Inspection by _5�k�"`°'P� Date Additional Comments: �� S Sl��fZ SW Z _ f r Applicant - Return all copies to: SAN JOAQUIN CO TY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 / FEE AMOUNT DUEAMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N0. INFO C /� 7 f 7 �/ (��1 r EH 13.24 IREV.1/"51 -7 'J Oji f /t,y/� / ! J 3'V� J -t