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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV I CES CANNED 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 San Joaquin County for a permit to construct and/or install the work herein described. This application is 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 _ / Z3,kee;g R D' City Lot Size/Acreage t Owner's Name ✓Q -- -l3R �l"I � __— Address >/1yga k RA45Z r 0 Phone 4 — 3'717 Contractor — Address License No. Phone } TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well C), PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ 6%ing tile)) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation _ Dia. of Well Casing Cl Domestic/Private! ❑ Gravel Pack El Tracy Type of Casing_ Specifications f_, 1'I Public 1.-1 Other n Delta Depth of Grout Seal Type of Grout [//f 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by c Repair Work Done L] Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material li Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION 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 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. b Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 Sen 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 subcontracting signature certifies the folowing; "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 Pcont,.must call for all r fired inspeecttiion&. Complete drawing on reverse side. � laG{ Date,Signed 0Wt FOR DEPARTMENT USE ONLY Application Accepted by ZY, J. Date 1 Area Pk or Grout Inspection by Date Final Inspection by r. �n , `Dau "� 1 Additional Comments: 1 r/7uG s' �;5 c}— f' 6 I-—Lam} ,r 9,_st Applicant - Return all copies to: San Joaquin County Public Health Services W( Environmental Health Permit/Services �jG� Pt - vl rY1fjY�c�fEt� 445 N San Joaquin, p O Box 2009, Stkn, CA 9520.1 ' l FEE INFO AMOUNT DUE AMOUNT REMITTED CASFI RECEIVED BY DATE PERMIT'N0, EH 12,24 IREV.1/0%5]W� I-qg0r-71 r4of EH 11.26