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APPLICAT--"iFOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Se 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. 509 and 1862 and the Rules and Regulations of San Joaquin County /Public Health Services. Job Address LL�% '�{� City r ,dLotiOSi(z/eJ//iicreage Owner's Name Address,-J�-J`�--/= Phone Con Trac toL/Sti€J License No.� Q Phone 5162- L .1 TYPE OF WELL/PUMP. NEW WELL ❑ it WELL REPLACEMENT G DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER ❑ Monitoring Well Ln 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing L�Oomestic/Private ❑ Gravel Pack ❑ Trac Y Type of Casing_ Specifications I'1 Public 1-1 Other fl Della Depth of Grout Seal Type OI Grout I I Inlgau°^ _"_.APProx. Deeppth I Eastern Surface Seal Installed by I Repair Work Done h/ Type of Pump `_�{, N.P. .2- State Work Donisi Well Destruction O Well Diameter Sealing Material 8 Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I ;SDESTRUCTION I I INoseptic system permitted it public sewer is .available within 20D.feel.1 Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms •� Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK ❑ rType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ /r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines r _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - Property Line I 1 , SEEPAGE PITS ( I DepiA. 1 Size _ Number ounon SUMPS LI Distance to nearest: Well Fdati _ DISPOSAL PONDS ❑ e Property Line h s I hereby sanity 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: 1 em by an r ' I Certify that in the laws ormance of the work for hir this permit is issued, sshallignature not P e person in such manner as to become subject to workman's compensation laws ss ed,California." Contractor'spersons hiring or sub-contracting signature certifies the following: "1 certify that in IDB performance of the work for which this permit is issued, I shall employ persona subject to workman" comp ca- non laws of California." � The applican/ta�/pa for all required inspe/s/jpns. Complete drawing on rave da. Signed X L�-�? A "e Gi/_L Title: �� Date: /FOR EPARTMENT USE ONLY Application Accepted by 5�. ,� - Date �d-lL Area Pit or Grout Inspection by Date Final Inspection by \ 5- Date-z l Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services p 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE pMOVNT DUE AMOUNT REMITTED ///I��N��F...O CASH RECEIVED BV DATE PERMIT'NO. EH U-]4 IREV,vem /� w EH 14 al 1_/" ✓�