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APPLICATION FOR PERMIT SAN ',%WAQUIN COUNTY PUBLIC HEALTH .woRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DA E 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County �Public jHealth services. (p Job Address I� I''''' rn''1/t&— qrt P_ Zs),) /,��Ciit_y� -''I'�'�`'� / [at Size/Acreage �//'� Owner's Name f��v` �^(�H✓ �/I.S; } Address a4#0'I fkN ` `'` '� S�Phone ZTO— -'7,�, Contractor "i;,� 041 Address P.0. 46 A J(10 vs! t C�License No. S�(63 1 Phon�2L) L-? L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n NDESTRUCTION ❑ Out of service Well O PUMP INSTALLAT19pN 8 ❑ SYSTEM REPAIR ❑1-6): of;A35 OTHER 9a Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES Zt)O DISPOSAL FLD. ag PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation r Cl Domestic/Private ❑ Gravel Pack ❑ Trac 7 Dia. of Well Casing Tracy Type of Casing Vc Specifications Nu I'1 Public n Other FI Delta Depth of Grout Seal A N6 _7LE_ ype of Grout+ttM'k tw k I I irrigation _Approx. Depth I 1 Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction O Wall Diameter Sealing Material A Depth Depth Filler Material i Depth 7 T� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 fast: Water table depth SEPTIC TANK. ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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, 1 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 mt/ft call an required inspections. Complete drawing onreverse sidq. / Signed X / Title: �l I.U� l/Te�r7`��; Date: � � pp FOR DEPARTMENT USE ONLY Application Accepted by 9k4=nE9 Pit or Grout Inspection b//yA�+p��yy Date p1 3 -r Final Inspection by� Daa J Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services .� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • EN 13-24 IaEv.lrxsl R�fl 21 86 l 6*fs q3-OAU EN 1411