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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION +t+� 445 N SAN JOAQUIN, PHONE (209)468-34¢1 P 0 BOX 2009, STOCKTON, CA 95201 *`�� \y a9 to , , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED%SaCPaV��N`'��Y�O (Complete in Triplicate) PN� Sc0P s>rse Application is hereby made,to Sm Joaquin County for n permit to construct and/or install t Lereln described. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and E es and Regulations of San Joaquin County Public Nealth Services. {��" n / Job Address / P SD 2: ^Rm 1C2./S' RC34 City Mar+,/ Lot Size/Acreage ®G .Sj>12CKG NJ Phone Z —3 /2 Owner's llama !� � ^ '• C �S GGrr ss ,f I ,u�/ t1 Contracts 8 SO Addres A✓L `2 /"rLKIt.Kf '1'6-'6 Contractor No.� Phone T Q� TYPE WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `'. Jr— A" FOUNDATION AGRICULTURE WELL JJ1dW— OTHER WELL--i@W PITS/SUMPS I ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /y� Industrial ❑ Open BottomManteca Die. of Well Excavation Dia. of Well Casing O Cl Domestic/Private Gravel Pacli7 ❑ Tracy Type of Casing , cl, $O PVC. Specifications I'I Public ❑ Other fl Delta Depth of Grout Seal Type of Groutp sr.a r"v'r Al I I Irrigation _.Approx. Depth i I Eastern Surface Seel Installed by8ini-,dZe LsncaS �eR Repair Work Done ❑ Type of Pump H.P. #-P StateDone_ Well Destruction ❑ Wall Diameter rSealing Material i Depth Work t: Depth gi 0' Tiller Material i Depth ;k9V0,/ { 0,6'' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sawer is \ available within 200 feel.) Installation will serve: Residence._ Commercial_ Other Number of living units: _ Number of bedrooms O Character of veil to a depth of 3 test: Water table depth O SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lim LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number ro SUMPS LI Distance to marssC Well Foundation Property Lina ") DISPOSAL PONDS ❑ 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 Hone 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 y 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 performane,of the work for which this permit is issued, I shall employ persons subject to workman's compen s� tion laws of California." The applicant must/scal�l for all required ins c ns. Complete drawing onf reverse side. Sigrsdx�s�yLf 7� ^ Title: /_/air ?�c�,l.��v Date: ICf I OR DEPARTMENT USE ONLY �— Application Accepted byW01�2Data res �(11 Pit or Grout Inspection by Date inal Inspection by Date 7 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services /•6 ✓� Environmental Health Permit/Services 445 N San Joaquin, P O Bot 2009, Stkn, CA 95201 INFO AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. fH u.]e