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APPLICATION FOR PERMIT 'y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR PROM 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 1662 and the Rules and Regulations of San Joaquin County Pub ic HealtA Services , _ry Job Address � `'� S �(rt�df- --- City 511DC<-TZP f Lot Size/Acreage 'v I -.] l�C Owner's Name . FST O� � Address Z�y) w- 4WASuI1146TCV4 -- Phone (�9 -146OZg6 ZA7,-5 C3FF,uTcr_- AAF _ ttfoy 4Z->•- Contractor 6�6� '6 " "TU Address Sf&JAL "I4 -- 5A IM- License IN o. " 5_7 4 65�& Phone � TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Cp`f OTHER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES %JA4 F.5._ _ DISPOSAL FLD, PROP. LINE l P FOUNDATION AGRICULTURE WELL !tit OTHER WELLV&S _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I lr INL4J Dia. of Well Casing +a'4 U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing NA Specifications f"`A ❑ Public Cl Other >CDelta Depth of Grout Seal wA Type of Group.1aF;J'C.;Wt:R 0 Irrigation Approx. Depth d Eastern Surface Saul Installed by_ NA Repair Work Dona L7 Type of Pump H.P. State Work Done _ Welt Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units; Number of bedrooms Character of toil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Propertt () wi Ea LEACHING LINE ❑ No. & Length of lines Total length/size � FILTER BED CI Distance to nearest: Watt Foundation Prop+Irf n 992 5 SEEPAGE PITS 11 Depth Sixe NumbePilRLIC: HEA[Ttt S SUMPS LI Distance to nearest: Well Foundationz�l�{It�{ AL DISPOSAL PONDS c) 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's compensation laws of California," Contractor's hiring or sub-contfacting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shale employ persons subject to workman's compensa- tion laws of California." The applicant must ca for all required inspections, Complete drawing on reverse side. Signed L Title: S 060 : Date: -��— ArymC"r`r FOR PIEPARTMENT USE ONLY Application Accepted by Date /,3 c Area Pit or Grout Inspection by ate Final Inspection byDate Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �� Sf 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201FEE J INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. . EH 13.24MEV.Iihsi3 Jq