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APPLICATION FOR PERMIT 1b A ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 3 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby sande to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccm{pliaice with San Joaquin County Ordinance No. 549 and 1862 and the Rules apd Regulations of San Joaquin County Public Health Services. Job Address 2�d.,/60/ 1,t/CS-r CpN�tsf City -�bCK�'/ Lot size/Acreage 2 70 hC[FS Owner's Name Ann-hltaw) cD HVG /"ltE.cWO`AP,ddress ��► F Phone O 9y �58W GS 8712• Contractor of 'xta.. ��.� rK Address.282SF. Mytrac S% License No. 1: �2Z68 phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XMonitoring Well L7 ROZZ4 DISTANCE TO 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Destructign (B Melt Diameter Sealing Material i aw Depth ,44awr AT. O ')O.ct e+rye- DepthC 30 fG>t'T Filler Material i Depth Mg TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will "me: Residence _ Commercial _ Other �'tc Number of living units: _ Number of bedrooms r Character of soil to a depth of 3 feet: Warte'i_iptileideptl4 \` SEPTIC TANK. ❑ Type/Mfg Capacity No.ZompgrtmaDta PKG. TREATMENT PLT. ❑ Mpp''athCCo�ol Qispµsal; Distance to nearest: Well Foundation Props4b e 1 f t'"t✓' LEACHING LINE ❑ No. i Length of lines Total Ieng1t/,Vfze FILTER BED ❑ Distance to nearest: Well Foundation ___ eropiertY lana `'-' SEEPAGE PITS 11 Depth Sirs Number � SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following; "I cenify 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 applic m t call for all required inspections. Complete drawing on reverse side. Signed X •� �' • //` Title: �•.a =<r Gla.�aG•!i Da � ] �F�PARTMENT USE ONLY Application Accepted by A . — Date Pit or Grout Inspection by Date Final Inspection by Dats Additional Comments. — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CR RECEIVED BY DATE PERMIT NO. INF,Or� / CASH,(/ . EN 1344(REV it R 51 L! /S U c— I EN a-p : Ll CCII