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s. , APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 l P O BO% 2009, STOCKTON, CA 95201 PERMIT -EXPIRES IYEAR R T ISSUED (Complete in Triplicate) Application is hereby msde to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance frith San Joaquin County Ordinance No. 549 and 1962 andJ�the Rules and Regulations of San Joaquin County Publliicj Health8ervices. Job Address 9 y itY Lot Size/Acreage (�� Owner`s Name Lofll -`'U. Address Phone f f OOS 7.)lPhone Contractor � Address License No. TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION p SYSTEM REPAIR 13OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing n DomestwPrivew ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'D Public fa Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done L7 Type of Pump H.P. Slaw Work Done Welf Destruction p Wall Diameter Sealing Material i Depth Depth Tiller Material ,& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ("'DESTRUCTION I I (No septic system permitted if public sewer is Available within 200 feet.) ' Installation w ✓ill serve: Residence Commercial— Other Number of living units: I Number of bedrooms -:3, :f� �!1 Character of Boll to a depth of 3 fest L.1 Z 0,-7 Water table depth CJ SEPTIC TANK. DI Type/Mfg Capacity CX7 d dCz _ No. Compartments Z-- PKG. TREATMENT PLT.❑ f Method of Disposal Distance to nearest: Well� Foundation �y Property Line t?U = LEACHING LINE I11-�No. 6 Length of lines O Total length/size FILTER BED O Distance to nearest: well�C� Foundation Property Line �v SEEPAGE PITS I I Depth Jo; F _Size 1 Number SUMPS L-Distance to nearest: Well /&12 Foundation C __ 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 Homs owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, 1 shall not empty any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting Wgnature 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 compsnsa• tion Tawe of California." The apple t!sisal 11 for a:,,�Oons. Complete drawing on reverse side.,/�Signed x �-----��• Title' (i/C�� Date: SOI--R DEPARTMENT USE ONLY A tion Accepted byL", Data�o�+ Area / a rout rS'pection by at Final Inspection by Dates Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEEVED by DATE PERMIT'NO. INFO �/L u�ryf� EH 13-24IIIEV.r/s5) D ,! �`� �� / t:H 14.30 I`.