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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 STOCKTON P O BOX 2009, , CA 95201 PE_MIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made,to Bed Joaquin County for a permit to construct and/or install the vork herein described. This application is aside in corepllance vlth Ban Joaquin County Ordinsnce go. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. �J Job AddraAddress /) �_eJ��S City,41 __� Lot Size/Acreage ' / /� ..//�� Owner's Nam, �G7 �B's�" ' , AA1dddress/Gv% 4 //�. Phone Contr •4�0 r AddreseN-i��NrvG '^"'r"` Lice" TYPE se OC�i103/-/3 Phone�s/� Sz•Q TYPE OFF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR D OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLO. PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r Cl Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing__ Specifications L)NK I'I Public 1'1 Other n Delta Depth of Grout Seal Type of Grout I I InitIation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Dona [J Type of Pump H.P. State Work Done _ n Well Destruction O Well Diameter Sealing Material i Depth �. Depth Piller 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 leet.l Installation will serve: Residence_ Commercial_ Other Number of living units. _ Number of bedrooms r^ Character of soB to a depth of 3 feet: Water table depth i SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TAEATMENt 6LT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED Ll Distance to nearest: Well Foundation Propeny Line ,/� SEEPAGE PITS 11 Depth Size Number G° SUMPS LI Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS O I hereby c*nify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state In". and rules and regulations of the San Joaquin County ISI Home owner of IfceAsed 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 lam of California."Contractor's hiring or subcontracting signature certtfiss the following: "I cenNy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compenss. tion law*of California." The applicant m/yet gall for all required 1 lnns�pgotions. Com late drawing on sverse,side, n ,/) ^ / ,, '�y,,.`- {.. tignted X�/ �,rT=�� /Tills: Clx/�U/� /17LJ1J�`��Oeta�'` j F/QR DEPARTMENT USE ONLY Application Accepted by v�,,".r�T`^"�"�'r"G ��'� '�� 1<�'-'�/�t�, \ Da Area PM a Grout Ins by rr'P7T.I//1(fii.0• Date Final Inspection by �✓d/T Date Additional Comments: - /�.,t>2�c�,X"f l-a �7z Applicant - Return All copies to: San Joaquin County Public Health Services ,t O Environmental Health Permit/Services 4455 N N San 9aa Joaquin, P O Box 2009, Btkn, OA 95201FEE /V/►//Vit/may } NFO AMOUNT DUE AMOUNTJREM-ITTED I �, / CASH AECEIvED BY DDAD ATE/7�,j PERMIT'NO. (� i . EH 11311 IeEV vxs1 EH 4.3114.311r!/f �n ,0 }�