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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOC%TON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PROM DATE ISSUED 2e� (Complete in Triplicate) Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccmpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 11 / -3 ,3 / 4 ltq, City b�'`' Lot Si"/Acreage Owner's Name � sgL� 2(l�s Address -1 f� 7cr Phone Contractor �j�V� ��4 Address S /aT E . TA ,cense No. C/s� Phone364 .Sa 17 i 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 n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing L O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ❑ litigation _.APprox, Depth ❑ Eastern Surface Seal Initialled by Repair Work Done U Type of Pump H.P. t State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION G INo septic system permitted it public sewer is \' available within 200 Ieai.l P Installation will serve: Residence A- Commercial _ Other - Number of living units: _/L Number of bedrooms Character of wit to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg FJ ftvCt-e-ft- Capacity D C No. Compartments 2- PKG. TREATMENT PLT. ❑ Method of Disposal was Distance to nearest: Well / -Foundation Property Line LEACHING LINE ❑ No. g Length of lines I - g2 0 Total length/size 7/�0x.M / FILTER BED ❑ Distance to nearest: Well /u� f Foundation /�d Property Line � SEEPAGE PITS 11 Depth Size � 3��fn yiz Number SUMPS LI Distance to nearest: Well Jt'Foundation/�O / Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San 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 sub-contracting signature certifies the following; "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion Iowa of California." The applicant must call lots all required inspections. Complete drawing on reverse side. Signed X I Title: -- Data: c�-9co FOR DEPARTMENT USE ONLY �{S liution Accepted be--tM yDate ,`2'� C2 U Area 2I / or Grout Inspection b Date(j L'y -5`J Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I I CASH lu SEN a-xs uEv.ir.atIIL4, 0 20 I1—Z8-5U J 31 EN'.baa 141