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APPLICATION FOR PERMIT SAN *QUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 vork 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 Health S�errviceess.Q ,1 �j j�.� ��/�f�-� Job Address 2_gy7 N • 1„`1V C City / �� A "'r"I Lot Size/Acreage w Oink t737 V, Owner'sName O 1-• 1�� f PE � Address y t �c�-� �`,1 t n 1A 14 04 T l D'T Phon �Oi �k- /:�Le Contractor PREGIS I�/J ljq.Yl'�QL(PJ Address Y! K/Vi7e 7f �T` 9 icense No.�Piton c�`� /fib -��1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monito ing Well ❑ 3AIRS', "� Z DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i V �Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Deli✓ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSf /! it ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing-3ILf Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specification— ('I Public 71Other fl Delta Depth of Grout Seal Type of Grout /"""\O t I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ We# Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public "we, is available within 200 feet.) Installation will so”: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of toll to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nesrest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Sime Number SUMPS LI Distance to nearest. Well Foundation Property Line DISPOSAL PONOS ❑ 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 canities 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 unify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must tall lora requaed insprrcti •. Complete drawing on�Arrewerse side. n Signed K Title: YiCO�Ur f//Q/2,8(��pC.DG��ate: FOR DEPARTMENT USE ONLY 9 Application Accepted by -v Date ` Area PK or Grout inspection by „( Date X19 Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services q o Environmental Health Permit/Services L 445 N San Joaquin, P O Boz 2009, Stith, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO Q p/ pCASH ,p q . EH sa(REV.vs 51 Ci I �� lO `�l1 4//�C 4 oQy"a EH l4.a