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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONhMTAL HEALTH DIVISION 445 N' SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE—ISSUED n ��ryry ��}}�� (Complete in Triplicate) ApplicatS&Pls1he4 i�Qde to San Joaquin County for a permit to construct and/or install the work herein described. This 1 apPlication is made in campliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Count PubTi�q #!. Services. I ENVIRO Job City 9k4�A,,17 Lot Size/Acreage Owner's Name �i�y � Address LE�,S'vt ,Lln��ft �7/Cc� /I,, / / Phone Contractor F3r1 Address 0 90)( 336 License No,ISYO_�Phone 7-3-7V- TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out ��oltff Service tfell ❑ C PUMP INSTAL Ott DISTANCE TO NEAREST: SEPTIC TANK�TI � SEWER LINESYAI.M REPAIR DISPOSAL FLD PRROP.INE p It FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing to Domesti Private ❑ Gravel Pack 0 Tracy Type of Casing_ Wr Specifications 1 I') Public I:1 Other 9 Delta Depth of Grout Sea, Type of Grout Il(6 I I Irrigation —Approx. Oepth I I Eastern Surface Seal Installed by �{ + • '!! Repair Work Done 0 Type of Pump H.P, State Work Done_ Well Destruction O Well Diameter Sealing Material t1 Depth s Depth biller Material i Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Install will serve: Residence Commercial_ Other ` Numbe►.of live Number of bedrooms Character of soil to a depth of 3 fee : Water table depth SEPTIC TANK. ❑ Type/Mfg Ca No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Lengt mea Total length/stz FILTER BED ❑ Dista to nearest: Well Foundation Properly Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 . 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, I shall not employ any person in such manner as to become subject to workman'&compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foMowirrg: "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 all for all roqpiipd Inspections. Complete drawing on reverse side. Signed X—. Title: Date: � � QQF��OR DEPARTMENT USE ONLY-, Application Accepted by �K^' _.._. Date �l r re Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services '3S.0 ' Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT R�EmITTED .j /_H res//�R7E[C�E['IIVV/ED BY DATE PERMIITT*N��O..] . EN l]-21 TREY.f i K sl �V 1 't � LH J&S-D f ✓�� -1 I r 3 !'y`�' \ EH 14•� ( .i .