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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-344913gPy, PERMIT EXPIRES 1 YEAR FROM DATE ISSUIM (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 yL!c� k)''Services. 11 ` l Job Address lCi • �nT•n�n.n R6 City 1--CA SA' Lot Size/Acreage I Lfz-`+- Owner's Name bQYIt�n Address c� Phone Conlraciof:rCbo<k Cr StAddress 7-:SO o - t.) ... License No. l-�lo if'�i PhoneQ - �!__r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER O Monitoring Well C7 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 U OP1m Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other U Delta Depth of Grout Seal Type of Grout G Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Wort Done U Type of Pump H.P. State Work Done _ r Wall Destruction ❑ Well Diameter Sealing Material i Depth 't� Depth Piller Material i DepthI TYPE OF SEPTIC WORK: NEW INSTALLATION EI REPAIR/ADDITION, DESTRUCTION D (No septic system permitted if public sewer is available within 200 feet.) Installation will NlVe: Residence DOCommercial �)/� Dthef Number of living units: _ Number of bedrooms Character of moil to s depth of 3 fast: - k c- .1 S;�`. 5 [ Water table depth SEPTIC TANK ❑ Type/Mfg 6lic, �-.� specify No. Compartments `4 PKG. TREATMENT PLT. ❑ c�-- D-P,tT/Jj - ��p ® tom-+ PO4 (�Yt.LYI[tggethod of Disposal w Dista l:CZ7V aXell Foundatiop� property Li o Dail d// ear/r.YNu� a� y�iv4'�' LEACHING LINE ❑ No. g Length of lines es _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Pfopeny Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` { ._;a G l c, Fhcts I hereby cenify that I hove 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 cenify 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 tail for all required inspgctions. Complete drawing on reverse side. Signed XN�� Tide: -t= t Date: Z — l9 –CAI FOR DEPARTMENT USE ONLY Application Accepted by ___ - Date pe Area 0?/3 Pit or Grout Inspection byDate Final Inspection by . Date Additions) Comments: -•1?�/� '.sJYc� r !- -f/�' •�f'L't�stc fi .� Applicant - Return all Coylas to/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES? 4451 NSAN JOAQUIN MENTAL TP OIBOXI 2009,ON PERMIT/SERVICES CCA 95201 ��t �lC✓.:< 7 �•/ INFO AMOUNT DUE ,AMOUNT REMITTED CASH I RECEIVED BY DATE PERMIT NO. • E EH Able H 19,14 IAEV.vssl �/ adv //y� 19J 1h4/I