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1;..,' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH ENVIRONmMTAL HEALTH DIVISION 'f 445 N SAN JOAQUIN, PHONE (209)469NV 1'f4E TAS,HEALTH P-0-BO~X-200 L, STOCKTON, CA 95201 P4RH f SERVICE PFMIT MIRES I YEAR FRQM DATE 109='-a PN 1: 33 (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 Rulea and Regula. 0 of San / Joaquin County Public health Services. �`O if COW'.COW'. 0/ W,i � City �� Lot Size/Acreage / l+f,J lob Address / �� cs� Li�A�if9�P J G D 7 %/tea s to Owner's Name Address �� ' � TCS n,9 �Q 6 y°4 5 , Contractor oqh n Address License No. l U Phone TYPE OF WELL/PUMP: ep NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION t,� SYSTEM REPAIR ❑ OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK T P1 I� FOUNDATION GRI LL WELL /S INTENDED USE TYPE OF WELL ROBLEM AEA CONSTRUCTION SPECIFICATIOAd kI 0 Industrial 0 Open Bottom O Manteca Dia- of Well Exca tion Dia. of Wall Casing 1"1 Domestic/Privaft �❑/ ravel Pack ❑ Tracy Type of Casing Specifications I.1 Public Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation 4AL Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Don_ Wag Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION i I DESTRUCTION I I Mo septic system permitted it public sewer is available within 200 fast.) - Installation will servenc : Residee_ Commercial_ Other Number of living units: Number of bedrooms Character of an*to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Wali Foundation Property Line LEACHING LINE 0 No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wee Foundation Property Line SEEPAGE PITS I I Depth Sae Number SUMPS LI Distance to nearest: Wen Foundation 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, state 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 pettonnance of the work for which this permit is issued,1 shall employ persons subject to workman's compenss- tion law"of California.- The applicant must colt for all requir i tions. Complete drawing on rover sides (l� �j Signed Title: ....1 L tate: _ `�" L LJ FOR DEPARTMENT USE ONLY Application Accepted by Data ' 3 Area ��`u~' Pit or Grout Inspection by Date 'Abs Final Inspection by Data Additional Comments: �L ��'� Applicant - Return all copies to: San Joaq5WCOUnty Public Healtv Services yq. 04) $avironmental Health Permit/Services 1 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED aY DATE PERMIT'NO. INFO . CASH E1rtl/. />S " 4-> --Ed Q77b /i/e- t t� f