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r APPLICATION FOR PERI[I T {' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FRAM DATE ISSUED I ) (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application in made in easgrliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County LPublic Health �Services. ^, Job Address _rsZ1/! [1.�6YiLd11�3„ City Lot Size/Acreage Owr'sNamaP1CJ �,_�(.�� Address1A�7 ��( A�,.� _ Phone r.. Contractor 4,rtvAddress License No. 0 9_ I Phone 1lf TYPE OF WELLJPUMP: NEW ELL ❑ WELL REPLACEMENT,'i-1 �4 DESTRUCTION ❑ Out of Service Well ❑ p "f Monitoring Well--��•--• . UMP INSTALLATION ❑�,. SYSTEM REPAIR w . OTHER ❑ p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial } ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V] Public 1 1-10 their fl Delta Depth of Grout Seal Type of Grout I I Irrigation t .Approx. Depth l I Eastern Su� a Seal Installed by Repair Work Done U Type of Pump t._ IP- N.P. State Work Done_ Well Destruction} ❑ �` Well Diameter --�LL2 Sealing Material & Depth - '"� Depth- LLVA r biller Material Ik Depth !� . TYPE_ OF SEPTICt WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I 1 IN 'if permitted if public sower is available wiihin,200 lest.) Installation will serve: Residence Commercial— Other Number of living units: f Number of bedrooms f Character of soil to a depth of 3 feet: '# Vllator table depth SEPTIC TANK. r ❑❑ Type/Mfg f Capacity # No. Compartments PKG. TREATMENT PLT. ` � ; � Method.of-Disposal"---.-,--- � , Distance to nearest: Well Foundation i Property Line$ LEACHING LINE] ;L1 No. 14 Length of lines ! Total length/size FILTER BED # r f - ' ❑ ri Q stance to Well Foundation r Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to_nearest. Well Foundation f, Property Lina DISPOSAL PONDS ❑ I hereby certify that 1 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 1r P" it owner or licensed agent's signature certifies the following: "I certify that in the petformahce of the work for which this pit Wissued, I shall not employ any person in such manner as to become subject to workman's compensation laws of Cslifornis."Contractor's hiring or iub-contracting signature certifies the following: "I certify that in the performance of the work for which this txrmi'is issued, I shall employ persone!subject to%workmon's compensa- tion#awe of California." The applicant must call for all required Inspections. Complete drawing on reverse side. Signed XTitle: + Date: �c FOFi DEPARTMEf11T,USE ONLY_„ Application Accepted by Date 41`52 Area / Pit or Groit#nspection by Date Final Inspection by Date Additional�ommsnta t Appl cant - Return all copies to: San Joaquin County Public Health Services EnvironmentalHealth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201CK 8 ; L .�} INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. i . EM13.24I11EV.t R01 Son I EM 14.20 '7 S l S: 9'-113-72-