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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 20090 STOCBTON, CA 95201 (209) 468-3447 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 work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. G Job Address /� es�/ / Y� Cit yr/ _ Lot Site/Acreage Owner's Nsma(�_ tEAIr `L�k� Address —tLv Alimm �-14 Phone _ i Contfa>t�r Addles r - License N Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL,9EPLACEMENT 41 DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TCT NEAREST: SEPTIC TANK" • "'SEWER LINES' " : DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE".OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS f_1 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications ID Public I-1 Other O Delta Depth of Grout Seal Type of Grout d IrrlOation Aplibw. Depth ❑ Eastern �—S-urface Seal Installed by Repair Work Dome, U Type•of Pump H.P; State Work Done _ TIN Well Destruction O Well filar ter Selling Material i Depth t Depth -7iller Hatarial g Depth r1 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 PAP'11R/ADDITI0N DESTRUCTION G tNo septic system permitted if public sewer is VVV i I available within 200,feet 1 Installation will serve: Residence--"Commercial Other ; z Number of living units: Number of bedrooms Character of &oil to a depth of 3 feel. • I Water table depth SEPTIC TANKY�O Type/Mfg i Csps;ity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Fdundstion Property Line LEACHING LINE ,F( No. b Length If lines 1 - iota) le gth/$!,a Q� FILTER BED ❑ Distance to nejrsat: w6Ni��'Ze Foundation -sem— Property Line 1�L SEEPAGE PITS Depth _SI3e Number SUMPS LI Distance torest: wait ne} 622 Foundation"% flroperty Line � DISPOSAL PONDS O , I hereby comity that I have prepared this appcation and that the work will be done in.sccordanoe W71nith n Joaquin county ordinances, state laws, and rules and regulations of the San Joaquiri County i Home owner or licensed agent's signature cer)tlfies the follovwing: "I certify that in the rforman,Jfi bfhe twork for which this permit is issued, t shell not employ any person In ouch mrr�rtner as to becpme subject to workman's comoensation laws of Celifbhiia." Contrscsol's hiring or sub-contracting signature eemifies the foI1ovJRtj"'I diff fy fhaf iri ttii performance of tie work for whico this permit Is issued) I shall irnploy pdrsons subject to workman's eompanss- tion laws of California." The applicant ust c ll for all required in ions. Comp)y*drawing on reverse side. SignedTitk: r' - Diets: LZ V OR �J NLY. �Application Accepted by tLN> yah, Date��"` t I Area Grout Inspection bv`\�CV1 Dated Kn4lntpection by , , Date r � Additional Comments; �- c,o.o AnoV od g 499��■d. pri' 1 - _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .._ ENVIRONMENTAL HEALTH-DIVISION PRUIT/SERVICES 446 N SAN JOAQUIN, P. O BOIL 2008, STOCKTON, PA 915201 INFO AMOUNT DUE rIYMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EHti 26 ri�5r t� teO //Zo7