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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DATE (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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. IS e 1/ Job Address City Old Lot Size/Acreage ' Owner's Name _e�`J a +�(� �.,Q tr�� Address a` 5 C' [�c2 R F � Gi - Phone 3 Contractor „4, Address PP D•Rej%L t a cl I V 99 �3 (o �7 ? License No� 3 Phon TYPE OF WELL./PUMP: NEW ELL ❑ WELL REPLACEMENT F1 DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well � 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 O L-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G C) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public 1-1 Other (1 Delta 'Depth-of Grout Seal Typo of Grout 1 I I Irrigation _.Approk. Depth I ) Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Wo r one �"� _ Well Destruction Well Di torr r� Sealing Material i Depth v e 99 AA UQ v Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITION I I DESTRUCTION I 1 INo 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 soN to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Wel! Foundation property Line LEACHING LINE Cl No. & Length of lines g Total length/size FILTER BED ❑ Distance to neerest; Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 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 Horsy 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 sulkcontracling signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perbns subject to workman's compensa- tion laws of California." r The applicantm t call for all required inspections. Ctuttpleta drawing on reverse lido. Sig f 4Y Title: Date: J0 a F EPARTMENT USE ONLY Application Accepted by Date Area - � �" F � � flZ Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: "'®" Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 I NFOMOUNT DUE AMOUNT REMITTED CK CkIVED BY p E PERMI7'N0. . EN 1}Zs IREY.yin SIY 1 •v/ +/ 1�EN 14-U �� ,�. I 61A I