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APPLICATION FOR PERMIT :-a SAN AQUIN COUNTY PUBLIC HEALTf VICES L (J WENVIRONMENTAL HEALTH DIVI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES T YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby asde.to San Joaquin County for a permit to construct and/or install the vork herein described. This application is cede 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 I'o L �1 E45� /{hIR� Ci'tyY-`"t � Lot Size/Acreage _ tu[:y ✓;Z KtVAfr-K?F °f.r�f�-KPY Address -LAI/tit:}r.}i+^ c} 161' ftiS� �p,�t AvZ,vL Owner's Nama c�_ Phone Contractor= i./E - L^• Address MEfdd CA 9)38 C9 License No. SDI Phone d5 391-$117- TYPE 9`I-$91LTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring Well L 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 ^ ri Ll Industrial ❑ Open Bottom O Manteca Die. of Well Excavation Dia. of Well Casing �( CI Domestic/Privue ❑ Gravel Pack ❑ Tracy Type of Casing-. t V� _ Specifications 1'1 Public - Cl Other fl Delta Depth of Grout Seat X15 r Type oIr�Grou1 I t Irrigation _Approx. Depth I I Eastern Surface Seal Installed by •vl �✓u L14 U!'�It Repair Work Done O Type of Pump H.P. _ State Work Dona _ Well Destruction ❑ Well Diameter Scaling Material L Depth Depth 53 Tiller Material i Depth �. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No asptic system permitted if public "war a available within 200 16411.) Installation will serve Residence_ Commercial_ Other �• Number of living units: _ Number of bedrooms Character'.of eoll to adepth of 3,bet: table rhpth __ SEPTIC TANK O },ype/Mfg Capacity No. Compartments •"'PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS If Depth Size Number SUMPS-- _. . '- LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby csnify that I have prepared this application and that the work will be done in accordance with Son Joaquin county ordinances• state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent9 signature candies the following: "I certify that in the performance of the work for which this permit is issued, 1 Mall not employ any person in such manner as to become subject to kman's compensation laws of California." Contractor'&hiring or subcontracting signature certifies the following: 'Y unify that in the performance of Ih ork for which this permit is issued. I shall employ parsons subject to workman'&compenu• tion laws of Catifornla." The applicant tt If f MI requsad inspections. Complete drawing oo/nn/reverse side. Signed K Titie:iiffit 0 �?✓✓ Dote: ��, 111 FOR DEPARTMENT USE ONLY / R Application Accepted by Data , ( 49 Ansa r �" Pit or Grout Inspection ,bY DDate? Fm I Inspection by Data Additional Comments: `^' Xs"'^.""--' W"�'S�J��Z�'� Applicant - Return all copies to: San Joaquin County Public Health Services Envlroaviental Health Permit/Servlcee - 445 N San Jokquin,,�x 2000, Stkn, CA 95201FEE 2L� �✓�� NFO AMOUNT DUE AMOUNT REMITTED CKSH._' RECEIVED BY DATE PERMIY NO. f! / • 0, .c . EN 1344 IREV.I1 51 EH 14-36 l7Ck� �