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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! ENVIRONMENTAL HEALTH DIVISION 1l°3a a. 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I ! PERMIT EXPIRES I MBAR FROM DATE ISSUED �. (Complete in Triplicate) Application is hereby made to $".Joaquin County for a permit to construct and/or install the work herein described. This application Is made in ccMliance with Ban Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Hoallth Services. Job Address Y /a 3,0 bi ��y � Cit Lot Size/Acreage Owner's Nam* s / T Address- -- .- _ - -Phone. ' Contractor �- Address License No-&&x.— Phone- TYPE OF WELL/PUMP: /t NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14onitoring Well ❑ ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE c,'FOUNOATION. -.--`� AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca _ Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public ;•%—.1 Other n Delta Depth of Grout Seal Type of Grout Irrigation 1 _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done r Well Destruction ❑ Wall Diameter Sealing Material i Depth C Depth. Fille--Watsrial A Depth `• .TYPE OF SEPTIC WORK: NEW INSTALLATION REPA - i R/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is Q .,�.�. avaitsWe within 200 teal) / '� �- Installation will servo: Residence-_____ Commercial Other b'ff 5 Number of living urtiti: Number of bedrooms Character of sole 6 a depth of 3.1sel: _ Water table depth SEPTIC TANK ❑ Type/Mfg Cepacityj�,'C-64 No. Comp mn@nts PKG. TREATMENT•PLT.0 �1 r!— Method of Oispo _tJSL� 1`�� tt "rte Distance to nearest: WON Foundation Property Line ��_ i..- F F / , / i LEACHING LINE D^ N.o:'3 Length of lines �r� �rT` Total length/size G� FILTER BED ? c ❑ Distance to neant: .Weil t FOundihon tom" Property Line h`'7`�T SEEPAGE PITS : I I Depth Size Number SUMPS Ll Distance to.nearest: .WON Foundation Property Line DISPOSAL PONDS ❑. ' s I hereby cenity, that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and 1 rules and regulations of the San JoaquinCounty 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 persons such manner as to become subject to workmen's compensation tows of Calif ornis.'.'A t ontrectors hiring or sub-contracting signature certifies the following: "I'certity that in'the performance of the work for which this permit is issued. I shall emptoYrs 'paons-sublactmsa .to w?rkan's compen • tion laws of CWfornls. e L I The applicant must cap for I requ'ed inspectlora:Complete dewing on r - Signed x Cmc- �,r dere( Title: _16r�--1'� D ate: I FOR DEPARTMENT USE ONLY i Application Accepted by { Date Area Z P r G t 1 by Date � �� Final Inspection by �! - .Date P . � � Additional Comments: - � Applicant,- Return all copies to: San Joaq9in..4310 y Pub11c'Heal:th S rvices i. Eovlronmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 05201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY GATE PERMIT NO. INFO CASH f-I yf . Er+13-24tAEV.1i�a1 .'�� cOD /f /� � , Z fN 14-35 /l t