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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 0 BOB 2009, STOCKTON, CA 95203 iERN T EXPIRES I XMR FR-9Y 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 coupliaace with San Joaquin County Ordinance No 549 and 1862 and the Rules end Regulations of San J0e41110 County�Public Health Services Job Address _ �7��Z�/c^3G/�L /7�1�L„ City �O 4 Lot bite/Acreage Owner s Name f/Y/�/�/, �oft/TTfts Address l?93 f Phone ConIIacIor/C��l'/"/AUAQ_filrC AddressRAlon' o ;/.e License No 21195�rsr6 Phone - TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Veli Cr 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 0 Industrial ❑ 0 •i pen Bottom ❑ Manteca Dia of Wall Excavation Dia of Well Casing n Dornestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ 1�f�C Specifications I 1 Public f-I Other n Delta Depth of Grout Seal _ Q _ Type of Grout J7, •, I i lrrgjationDApprox Depth I I Eastern Surface Seal Installed by . i Repair Work Done 0 Type of Pump H p State Work Dona Well Destruction ❑ Well Diameter See-ling Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRiADOITION i I DESTRUCTION I I iNo sepiig system permitted if public sewer is available within Z00 feet I Installation vv,ll sarw Res4ence _ Commercial— Other Number of Irving unite Number of bedrooms Character of sod to a depth of 3 feet Water table depth SEPTIC TANK O Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE Cl No 8 Length of lines Total length/s4ze FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws, and rules and raguLatgns of the San Joaquin County ' Horne owner or licensed agent s signature candies 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 mariner as to become subject to workman a compensation laws of California ' Contractor s hiring or sub-contracting signature certifies the fogowing I certify that in the performance of the work for which this Permit is issued,I shall employ persons subject to workman s compensa bon Laws of California " The applicant VS1 cap for all required inspections Complete drawing on reverse side S'gr*d Title Date 5;t-'Zz—9/L Application Ace FOR DEPARTMENT USE ONLYLJ Accepted byy e0 Y Date f �-2— Area UYL l `T Pit or Grout Inspaction by Date _ Final Inspection by I Date Additional Com r"ts (eq3(kF4Ct L Ave. ZAPN 'FL ,Z Applicant - Return all copies to San Joaqui County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 1009, Stkn, CA 95201 INfC AMOUNT DUE AMOUNT REMITTEDF4qo H RECEIVED t1Y GATE 1'EftM17 N0 Em ,}_.I,ir► i,ii ai �- q �— q.ZZ•�z�Z-323 Ela+i4>s