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APPLICATION FOR PERMIT SAN J(NQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 in made 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 6h'ZS"P�/ C CityD� T� Lot Size/Acreage Owner's Nampa l/�'/�/f/ oit�TCS Address fT0 S^ �/�J�Lp '�Y S Phone z �r Contractor/C�XV��a�/D/7 � L Address��a Y�/fon' ff�11!-irA License No.Zrsr6 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR Cl 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 1_1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private O Gravel Pack O Tracy Type of Casing_,___ /p�C Specifications r�13 I'l Public 1-1 Other FI Delta Depth of Grout Seal S� _ Type of Groutd/i Xel,., I I Irrigation ,L�Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth i Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) / Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of 504 to a depth of 3 feet: p Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal / Distance to nearest: Well Foundation Property Line LEACHING LINE L-I No. 6 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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 $t call for MI required inspections. Complete drawing on reverse side. ��/ C� Signed Title 0 ///�Z4tR"'— Date: FOR DEPARTMENT USE ONLY Application Accepted by h Date Area UVI( I Pit or Grout Inspection by //�1 Date a/�' 2 Final Inspectionby '^C ( Date Additional Comments: 5112 STt14V lVIie,1,c1 6g31(c f4c( (L AVe. Z1PN $1-2(oo-Zo Applicant - Return all copies to: San Joaqui County Public Health Services MW�I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 11 CASH RECEIVED 8Y DATE Q 7 PER2M�I7T�NO. . EH,3-N 1REV.i/n s) °� °�— 4�D /t ( -2Z EH 1426