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0 APPLICATION FOR PERMIT t SAN JOMEUIN COUNTY PUBLIC HEALTH SEMVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is snide 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 �y.?s" / o7G/✓/G //!�G• City _67— Lot Size/Acreage Owner's Name J� /Zlr z1*D�CO�T//8.f Address 1.7 ilJ J: 4 >�fC�G]If �� G Phone Contraclor/�T��Tb/7 � 1 Add,, d/rit/�K /I�tfY�f� License No.zi S Sb Phone TYPE OF WELL/PUMP, NEW WELL 2 — WELL REPLACEMENT Fl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well 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 ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing �j [I Domestic/Private O Gravel Pack O Tracy Type of Casing_Z at!G Specifications I'I Public (I Other Fl Delta Depth of Grout Sealr�sr- Type of Grout S�/XX I I Irrigation LQApp(ox. Depth I I Eastern Surface Seal Installed by 1916 "ex. t f� Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.)Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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... q q Signed HE7lltl�i/.Aim Title:, -ro` /��Xw.�"t— Date: Q FOR DEPARTMENT USE ONLY Application Accepted by 'W Data /� •91Area .r.tii P �� L (� , _e Date �7 Pit or Grout Inspection by _ Date / ,/ //Final Inspection by Additional Comments: 5 (,qc) f C � P <91-�p0 Applicant - Return all cop es to: San Joaquin/County Public Health Servl es Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE�j7 9PERMIT NO. . EH 13.24 111EV.1/n 5) �q OZ7 T� O� 4qb � 22•/!i 12-3 EH 14-M VV !!