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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 N0�14$ C PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` • �" S/27�r�' { (Complete in sraTriplicate} Q �� Application is hereby de.to San Joaquin County for a permit to construct and/or install the work'herein deacic]7bed. This application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name CILLSk Address Phone Ll3' 165V�d ./Contractor w Address License No, Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C3 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENC ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industri ❑ Open Bottom 0 Manteca Dia. of Well Excavation pia. of Well Casing C) Domesti /Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public n Other "171 Delta' `r"' Depth of Grout Seat Type of Grout I I Irrigati Approxi Depth 1 1 Eastern Surface Seal Installed by Repair Woi c Dore L] Type of Pump H.P. State Work Done_ Well Destrt ction 0 Well Diameter Sealing Material i Depth i Depth Filler Material i Depth TYPE OF EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIDN (No septic system permitted it public sewer is available ithin 200 feet.) Installatil n will serve: Residence-__ Commercial Other NumbIrf living units: Nu r Chwaof soli to a depth of 3 f r-ta y TA SEPTIC TAS K. 0 Type/ g city No. Compartment PKG. TREAITMENT PLT.Cl permit mai, haVe e �� Method of Disposal f Distance to,f�rTteingW Property Line �� LEACHINGINE ❑ No. 6 Leng l tr. ..1 I Total length/size V FILTER iBE 0 Distance -rSearest. We I Foundation Property Line 3 SEEPAGEPI S Depth Size Number' SUMPS LI Distance to nearest: well Foundation Property Lino � DISPOSA , DS ❑ I I he certify that I have prepared this application and that the work. ill be done in cordance with San Joaquin county ordinances, atnla lawd and Home owner or fio� ort �iyen s rformance of the work for which this i4rmit is issued, I sh 11 not employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the wolk for ich this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for an required in coon Completedr > ing reverse side. j/Signsd X. tie- Date: FOR D PAj TMENT USE ONLY Application Accepted by / Date Area l Pit of Grout Inspection by ate Final Inspection by Date Additional Comments: { ' r Applicant- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 446 N San Joaquin, P O Box 2009, Stka, CA 95201 FEE i INFO AMOUNT DUE AMOU REMITTEDCA5H CEiVEp BY ATE PERMIT'NO. �t �j � . E11 13-24 tpEV.I/K a> EH 14.20 1