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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL R.EALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468- 3i/ PERMIT EXPIRES I YEAR PROD DATE_ 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 coniplisnce with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. `pr, Job Address �� U S_c mer y nA. City Lot Size/Acreage Owner's Name .--i /_9AS S Address 1 V 6-4 9 I/gcM NML Phone ContractorA pL-ea a Bc lUca —Address « / 4, GR YA9A/frcJ License No. v Y- Phone - I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout Ci Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION M DESTRUCTION i=1 (No septic system permitted if public sewer is available within 200 last.) installation will serve: Residence' Commercial— Other. Number of living units: I Number of bedrooms 3 t Character of soil to a depth of 3 feet: Water table l pth Q SEPTIC TANK d Type/Mfg —p,L_L_ Capacity !4d U No. Compartments �- PKG, TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well MURT Foundation !O Property Line LEACHING LINE C1 No. A Length of lines Total length/size 3D FILTER BED R ' Distance to nearest: Well fes_ Foundation'10 ` Property Line / 7Lc.Q -kS /o ck SEEPAGE PITS 11 Depth Size 2'Z z Number SUMPS Ll Distance to nearest: Well Foundation Property Line a" DISPOSAL PONDS Cl 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: "I certify that 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: -v e Date: IP:�N_,?-�T..._. -FOR_ DEPARTMENT USE ONLY `/ Application Accepted by Date Area .246Pit Or Grout Inspection by Date Final Inspection by !--1, Date p�- Additional Comments: o Applicant - Return all copies to: SAN JOAQUIN COUNTY PUB C HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT�NO. EH 3c?b