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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 r PERMIT EXPIRES 1 YEAR FROM D T 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 ecagtllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6 v 5 4 zuku II �{9P City Lot size/Acreage 3Z �`c., Owner's Name AT—Address AvlePhone 4�3a-- e� Contractor /yam Address �tX ` License No. aM: hone .7 TYPE OF WELL/PUMP: NEIV WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C]PUMP INSTALLATION 7 DISTANCE TO NEAREST: SEPTIC TANK �f�U�r�r 77-tSEWER LINES DISPOSAL FLD.�� PROP. LINE FOUNDATIONAGRICULTURE WELL ' OTHER WELL �! PITS/SUMPS INTENDED'USE' ---TYPE-OF-WELL,--'PROBLEM-AREA—CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing XDomastic/Private Gravel Pack nom+ Tracy Type of Casing_— Specifications C� - I'1 Public 1_10 Delta etpA r t�t1 Delta Depth of Grout Seal Type of Grout fir I I Irrigation A prox. dl astern aprface Seal Installed by f V,Repair Work Done 0 Type of Pumpy H.P. e�_ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other �n Number of living units: Number of bedrooms Character of soll-to a depth.of 3_feet:_ Water table depth - SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest, Well Foundation Property Line LEACHING LINE Cl No. m Length of lines ' Total length/size FILTER BED u ❑ Distance to nearest: Well Foundation Property Lina \ SEEPAGE PITS 11 Depth Size .Number 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:"1 caftiWthat 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 applican 1 MI tions. Complete drawing on rejer side. Signed Title: 4 Date: A�_ t y F DEPARTMENT USE O LY Application Accepted by Date r- Area Z 7 Pk of Grout Inspection by � ate Z ' � "4 3 Final Inspection by Date � Additional Comments: n Lk Applicant - Return all copies to: San Joaquin County Public Health Services C1 Environmental Health Permit/Services �— 445 N San Joaquin, Bax 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY PATE PERMI7'NO. 4 3, INFO . EM 13.24IIIEV.Iirr51 EM 1 1.20 YG�