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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 0 BOX 2009, STOCKTON, CA 95201 PERNd T R IRKS 1 YEAR ERQK DATE—I.§SUED ` (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public ��Health Services. Job Address V a . Cit 104� Lot Size/Acreage r Owner's Name�� AddressPhone �s 7 Contraca7 ,Addre V ,� License. �� Phonr TYPE OF WELL/PUMP: -NEW WELL - WELL REPLACEMENT 17 DESTRUCTION Ll out of Service Well ❑ PUMP INSTALLATION !fY SYSTEM REPAIR AD OTHER 0 Monitoring Well ❑ ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fL INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS k n Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public f-1 Other f'I Delta -Depth of Grout Seal Type of Grout I 1 Irrigation ...�.Appr m' Depth I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump W13 --- State Work Done Well Destruction p Well Diameter `'Bealing,'Material i Depth Depth Tiller Ititerial-;.Depthr� - + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is A in v available within 200 feet.) �insiatltitioriwiEl serve: Residents Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK O Type/Mfg Capacity^ _ No. Compartments PKG. TREATMENT PLT, 0 i Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No, 6 Length of lines Total length/size Ll� FILTER BED 0 Distance to nearest: Weil Foundation I Property Line SEEPAGE PITS 11 Depth- Size Number SUMPS Ll Distance to nearest:. Well Faundsiion �. �: _. - � I Property Line wDISPOSAL PONDS' ❑ . - I hereby certify that I have prepared this application and that`the work yiill be done in'accordance With San Joaquin county ordinances, stats laws, and ` rules and regulations of the San Joaquin County. ;• r Home owner or licensed agent's signature certifies the following: "l 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 Csiifornia Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l$hail employ persons subject to workman's compensa- tion taws of California." Thea t applicant must a or all required ' peclions. Complete drawing on verse side. •-_��-----. Signed Title: �'�"�Dtite. I� FOR DEPARTMENT USE ONLY + Application Accepted by A& mab t gA Date 9 tea Additional 111 Ph it Grout Inspection by Data Final Inspection bytnv Date ional Comments: Applicant - Return all copies -to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San l Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE ., AMOUNT REWTI-yjO �" ' INFO CK RECEIVED BY CASH" DATE PERMIT'NO. • EEM 13-24 N 14-MiAEV.ris1S1 �� 35(' + -