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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 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 Se made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San �Joaquin County Public Health Services. �J �z /Job Address �_ :� N� A /� f�J7 CItY/+ ✓ rG ;Lot Size/Acreage �C- l Owner's Name 1�yri l�C/T�.T l�/ !/Address ' C6' • Phone F ? s' tbrtlydctarE>t�-!>' � Si2� }'elQIJ,Address.. l�� 1E�i •OyI`+�__ is AE '.6 P_hD i- "t�'3. TYPE OF WELL/RU 1�P: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O of Service Well O PCIMIASTALLATION ❑ SYSTEM REPAIR O OT Monitoring Well DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL F PROP. LINE FOUNDATION RICULTURE WELL OTHE WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA NSTRU SPECIFICATIONS Ll Industrial O Open Bottom ❑ Manteca Di Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing _ Specifications M Public 1-.1 Other a Depth of Grout Seal _ Type of Grout M Irrigation —Approx. D th O Eastern Surface Seal Installed by Repair Work Done U Type mp H.P. State Work Don Well Destruction O all Diameter Sealing Material a Depth Depth Filler Material a Depth /TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑ DESTRUCTION CJ INo septic system permitted if public sewer is h available within 200 feet.) Installation will serve: Residence . Commercia Other Number of living units: _L Number of bedrooms 4 Character o1 soN to a depth 3 feet: Water table depth SEPTIC TANK. �ype/Mfg l-° �t . le -specify v //el No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line /LEACHING LINE No. g Length of linea � Total length/size i FILTER BED CtT Distance to sasses: Well/!�0 Foundation Property Line SEEPAGE PITS td Depth Size IJ i/ _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 San Joaquin County Home owner or licensed agent's signature cemifies 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 candies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa. tion laws of California." The applicant pmust call for all r ired inspecho .. omplete drawing on reverse side. Signed X./ Title: fA� Fli DEPARTMENT USE ONLY q Application Accepted by c..... '1N.i -- -- . .� Date I res Pit or Grout Inspection by Date Final Inspection 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 95201 INFO FEEAMOUNT DUE `` AMOUNT REMITTED / -ASN FN 13-24 IRRECEIVED BY DATE.+/.�/ QPEiRMIT'1N(�O. EV,irxal 1 r • � �'�� II Y1�J-' .EN:bM I