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APPLICATION FOR PERMIT i SAN �QI3IN COUNTY PUBLIC HEALTH f'� VICES i ENVIRONMJNTAL HEALTH DIVISI� • 445 N SAN .-JOAQUIN,. PHONE (209)468-3420 P 0 BOI 2009, STOCKTON# CA 95201 PERMIT-EXPIRES :L YEAR FROM DATE ISSUED (Complete in 'Triplicate) Application is hereby teade'to San Joaquin County for a perait to construct and/or install the work herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / / u� et07-� Lot Size/Acreage Job Address City �►S f/ q sfrr11J Owner's Name 14 111 i i5 rJ CF (7-0 Address 1J W, ��'�.�C S , — Phone PO 6O?�, tlg3J G-SZ� Contractor 2 70GAddress License NO.*--SZ /2__Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 2s ' DISPOSAL FLO. " PROP. LINE '30 FOUNDATION rJC� __ AGRICULTURE WELL . OTHER-WELL.Z/ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ttdustrial ❑ Open Bortom ❑ Manteca Dis. of Wag Excavation Dia. a1 Weg Casing 17. me l Dostic/Private ❑ Gravel Pack ❑ Tracy Type of Casing U(- Specifications I"t Public Other Delta Depth of Grout Seal Type of Grou I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done Wag Destruction ❑ Wolf Diameter rl Sealing Material i Depth q Sfv"IF^�r Depth . !2 tiller Material i Depth TYPE OF SEPTIC WOAK. NEW INSTALLATION I I REPAiA/ADDITION ( I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 lost.! Installation will arse: Residence Cornenercial Other _ Number of living units: Number of bedrooms Choraetsr of soli to a depth of 3 feat: Water table d� SEPTIC TANK. ❑ Type/Mfg Capacity No. C are PKG. TREATMENT PLT.❑ t of poaal DWtsnco to nearest: Well Foundation Property LEACHING LINE Cl No. #Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wag Foundation Property Line SEEPAGE PITS I I Depth Sias Number SUMPS L1 Distance to nserast: Wed 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 trw San Joaquin County Horne owner or licensed agent's signature cenifiss the following: "1 cortify that in the performance of the work for which this permit is issued. I shall not employ arty person in such T7u," to become subject io workman's compensation laws of California." Contractors hiring or subcontracting signaturs Certifies the following: "1 Coin t performance of the work for which this permit is issued,I shag employ persons subject to workman's compensa- tion laws of orrda." The st�for ' in ions. Complete drawing on r era side. sign ^ Title-. Osie: FOR DEPARTMENT USE ONLY 5 E Application Actspted by Date ( ' Area 0� Pit or Grout Inepectiom by Oats Final Inspection by Oats Addhional Comments: Applicant ; Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 448 N San Joaquin, P O Box 2008, Stkn, CA 95201 FEE AMOUNT OUE AMOUNT REMITTED CKs RECEIVED Sy DATE PER M17,NO. INFO CASH . EMIlIstRiV.fSr wM gig, LaeMDQ s �•Z�. y -E14I Ftt t4as