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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 PERMIT EXPIRES 1 YEAR FROM 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 compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. rr,w�.. Job Address Q !�'Z�T City JeQDI Lot Size/Acreage Owner's Name Address 12 d JP D I CA Phone 30 r w¢(�bDWAXD V 11WA NCS Contractor L cbi4tlg�"[` Address &3 W MAQ1+{' L�License No. �39 Phon -0 l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fLD. _ PROP. LINE FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS 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 W14 Specifications i'3 Public 1-1 Other I"1 Delta Depth of Grout Seal Type of Grout AAWAWP ay. { I I Irrigation —Approx. Depth K Eastern Surface Seal Installed by 0A k;_ Repair Work Dorm ❑ Type of Pump H,P. tate Work Dona_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth J1 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I ) 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 P Character of sols to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line rnrn LEACHING LINE C1 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 regulatiorn of the San Joaquin County i 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature eartifiss the following: "I certify that in the performance of the work for which this permit is issued, I shah employ persons subject to workman's compensa- tion taw of California." The spplicant t ca!l#br ctions. Complete drawing on reverse side. Signed X Title: jF4fjVgg� G_J Date: —zf-93 FOR DEPARTMENT USE ONLY - Application Accepted byData 12- P Pit or Grout Inspection by Date Final Inspection by Date Addhionsl Comments: is Applicant - He all copies to: n Joaquin County Public Hem Services Environmental Health Permit/Services C) 445 N San Joaquin, P 0 Hoar 2009, Stkn, CA 95201 FEE C INFO AMOUNT DUE AMOUNT REMITTED GASH CK 4' RECEIVED BY DATE PERMIT'NO. . EH 13-24 OtEv,I/As) � ,fir / 67 e ,O EH 14.28