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Y APPLICATION FOR PERMIT SAN VAQUIN COUNTY PUBLIC HEALTH &VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON , CA 95201 PERMIT EXPIRZSS I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sao Joaquin County for a per=t to construct and/or Instate the work herein described. This application is rasde In coetpllance vith Sea Joaquin County Ordinance No. 51j9 and 1862 and the Rule■ and Regulations of San JOaqula County Public Health Services. '7 G � Job Address -SaL Ci-'+' -e- sr/'�.c/! City SI ei��l o+a Lot Size/Acreage LLl}[3 qrd Owner's Name C�i✓r&'t LW 4 PA'r�� Cc. Address r`'7lV CCXJaLrrw�QNtitk/l_. SCL�t_1C � Phone S/D ��z' 5 y Contracts ajl EX ,o cit Or(U 6 Address I o &o� E,7-13 / ��a~- License NoQS-7-T-U L Phone 7°7 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS , Monitoring ue11 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �a• DISPOSAL FLD. Sof l ��r LJF E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (-) Domestic/Private Cl Gravel Pack C3 Tracy Type of Casing Specifications 1'1 Public n Other n Delta Depth of Grout Seal s,„F'-iPT Type of Grout NeZrCf'",* I I Irrigation ^Approx. Depth t I Eastern Surface Seal Instilled by Repair Work Done L7 Type of Pump ii.P. State Work done pr-r 11 Sur ba`r KKiS Seals Arterial ti Depth IJr�-r C-r_'_oALt Zr M-, / Well Destruction ❑ Well Diameters` n8 �'p O T Depth ` Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation wilt serve: Residence_ Commercial— Other Number of fivtng units: Number of bedrooms Character of soli 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 ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distan" to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distarwa to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certrty that I have prepared this appircatrOn and that the work will be done on accordance with San Joaquin county ordinances, state laws, and rules and regulatwrsa of the San Joaquin County Nome Owner or licensed agent's a+gnsture certifies the following: "I Certify that in the performance of the work tot which this perrrut is issued, 1 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 cemty that in the performance of the work for which this pernut Is issued, I scull employ persons subject to workman's compensa- tion taws of California.-, The applicant must call for ail r urod +nspectrons. Comoosts drawing on reverse side, n -7� Signer Title: Sc�u � GtGI s i S/ Date: FOR DEPAATAAENT USE ONLY Application Accepted by pate Aram Pit or Grout inspection by Date Final Inspection by Date additional Comments: Applicant - Return all copies to: Saa Josauin County Public Health Services Environmental Nealth Permit/Servicee 445 N Sao Joaquin, P O Box 2009, Stkn, CA 95241 INfO FEE AMOUNT DUE AMOUNT REM"'o CASH RECEIVED QY DATE PERMIT NO. EM t}24 IREV L Ins? EM r�.i