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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 work herein described. This application is made in coMPllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public)Health Services. ZJob Address rC,13 &yV I2rfye City 5710G foil Lot Size/Acreage Owner's Name K(r K ��.e4 / Address frX biaw /V.y, A) 14 / Phone // &S/ 4 7d / / z3 6y iv;,7Jw�( � Drive <'S7 zcr Contractor r- - ddress .S' y�C }l9[� C/t License No.--7 ZZ Phone , Q TYPE OF WELL/PUMP. NEW WELL 2k- WELL REPLACEMENT P DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER X P. Monitoring Well ❑ &�r;Hgs 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 E Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation tt--Lhdi Dia. of Well Casing Q(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications i'i Public 1-1OtherWDelta Depth of Grout Seal Type of Grout I I IrnIgatron ) Approx. Depth 1 I Eastern Surface Seal Installed by " Repair Work Done ❑ Type of Pump H.P. State ork Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sews, is available within 200 feet.) Installation will serve: 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 Lina LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to neatest: 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, 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californle." The applicant mus[ call for all required inspections. Complete drawing on reverse side. C Signed )L .nnnnz :7y1"V-1ST, Title: �rc�}r r:1' 7i/ .P.✓'y'I Sd/" Date: 07 9 FOR DEPARTMENT USE ONLY Application Accepted by Date Area ✓✓� Pit or Grout Inspection by TVA net. Final Inspection by Data 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. //I /,, . EH t}1t IeEV.i,.,l 3� 9 IQ LV Vln� 2f6 1� fH leap