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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION ! 445 N SAN JOAQUIN, PHONE (209)468-3420 j P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM- DATE_ , SL SUED (Complete in Triplicate) i 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address ` /,0 City%S't-bC=k4-a k%-Lot Size/Acreage t Owner's Name (f'� Ike `!k1m,✓-------�Address, .��' I'`iy k r, , l Phone Contractor --�Z.i1Q. �O�I ��3t / Q�L10 .�. �1 cry �-6/,le- d ss •� ! 0 ` 'Lic�nse No. 3-I [�+�hone7� 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl Diff l0N pi.Out of Service Weil CI + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Y 6 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done , ,Well Destruction 0 Well Diameter Sealing Material 4 Depth i Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION.I InREPAIR/ADDITION Id DESTRUCTION (No septic system permitted it public sewer is ' r { available within 200 }eat.) Installation will serve: Residence ! Commercial— Other j Number of living units: Number of bedrooms,. tCharactar of soil to a depth of 3 feet: Water labia depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ; �a Distance to nearest: Well Foundation Property Line }I LEACHING LINE ❑ No. & Length of linea Total,length/size FILTER BED 0 Distance.to nearest:+vers*Well Foundation Property Lina" - -�+,,,• SEEPAGE PITS 11 Depth Size Number I""- ; SUMPS LI Distance to nearest:11- Well Foundation --iPrope ry ins*" ..i DISPOSAL PONDS ❑ s. ,► • , l! a,- -J;}• z°7 I Hereby certify that I have prepared this application and that Uri work will be done in accordance with San Joaquin county 6rdinances, state laws, and rules and regulations of the Sen Joaquin County i lI , i'A '11. 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 0"" loy any person in such manner as to become subject to workman's compensation laws of California." 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, 1 shall employ persons subject to workman's compensa- tion Is of Ca ifornis." _ The applicant ' call for Ni rspu ti, :T 7on's Complete drawing on reverse side. sigma, Title: —rbate: OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit L2 9Z PK tx Grout Inspection by Date Final Inspection by Date � Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Env445 NoSan Joaquin, Health Permit/Services - 445 N San Joaquin, P O Box 2009, Stkn, QA 95201 INFO AMOUNT D/U9EJ� AMOUNT REMITTED /CJIIIyAySH RECEIVED BY DATE PERMIT'NO. FEE . EH }2�IAEV.r/�S � � I EH I4•Ia l/