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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 O 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 coewliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pubes 4CC th,$ ffol ezp sa FN, CA4 C A M YI J � �Q FIE'ENS 1-t C�v►�� ob Address 55 �—LLKK City / Lot Size/Acreage 2 � s Owner's Name �� i • �C�itR+� Address `] 1 L' OZ1 C-6(JGH Can? F0 Phone /8Z'0 LGJ kontractor Ow tui ;& Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \\t 11 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F 1 Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing__ Specifications I'I Public 1-1 Other I—I Delta Depth of Grout Seal Type of Grout 11 11 Irrigation _ Approx. Depth 1 I Eastern S ace Seal Installed by ` Repair Work Done A,- Type of Pump S U - - H.P. State Work Done _ \, / i Well Destruction O Well Diameter Sealing terial Depth Depth _Ld Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is C' available within 200 feet.) \ Installation will serve: Residence_ Commercial_ Other (C. Number of living units: Number of bedrooms Character of 600 to a depth of 3 feet: Water table depth (�\\ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENY PLT. ❑ Method of Disposal v Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEFPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to nearest: Well 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shell 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 ust call for MI required inspections. Complete drawing on reverse side. Q d /J Signed X Title: 0(.V Al JQ_ Date: / /��(�/ F DEPARTMENT USE ONLY Application Accepted by LAY 4...� _ SiaA Date 2 1'— res Pit or Grout Inspection by Date Final Inspection bK Datt/1� 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 FEEINFO AMOUNT DUE AMOUNT REMITTED C K H ECEIVED By DA E PERMIT NO. fHu24(REV i,mei fH 4.ze