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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEQ (Complete in Triplicate) Application in hereby msde,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is wade in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public � ( HealthhServices. Job Address Srj 12, C City_57,ZYA ) Lot Size/Acreage _ Owner's NomeL)r:-5�'�� _ _ Addressy /7 I n Phone 1C,�L'a✓L7 Contractor c> ' 1- Address / License No. q32-1LPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 fl Industrial CT-0 pen Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing U Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _.Approx. Depth O Eastern Surface Seal Installed by r_ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION G (No septic system permitted it public sewer is available within 200 feet.) CJ Installation will servo: Residence— Commercial— Other R2vleZC�e I-cc/LeyD Cc Y)k Number of living units: _ Number of bedrooms Charocilm of soil to a depth of 7 feet: � 'Inn. Water table depth SEPTIC TANK X Type/Mfg 6 Capacity J — No. Compartments PKG. TREATMENT PLT. ❑ Method ooff^Disposal c� Distance to nearest: Well 50 Foundation Property Line X .- LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED 11 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 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 Califomia." 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 NI reaui na tions:Complete drawing on reverse side. �--'�� // SignC�e3�4�iLn-P �i� S� Title: Date: / ` es- y �(\�1 FOP P TMONLY S Application Accepted by c- -"cAw� -a -a �L 4^w^ Date 5L� O- `� Area y Pit or Grout Inspection by Date Final Inspection by Date O . Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY .S DATEPERMIT NO. Etlx 1119V. sr M ,1• 7 — CA - s I/ _ I I I_ . "0 1_t�a1