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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 PERMIT EXPIRES IL 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 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 !2' 6g LAe,,k� )>k City _ _ w � Lot Size/Acreage yarpitr6 �/SS�oNAQ y �` f �. Owner's Name C'�� '"/A'e! .C !/�Q� _ Address -�iF�rl� Phone Contractor�io,�� ,�, Address ` cenT se a45YfY7G Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out o- Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring dell 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications l•I Public fl Other f1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation T Approxi Depth I I Eastern Surface Seal Installed by, Repair Work Done ❑ Type of Pump H.P.' State Work Done Well Destruction 0 Well Diameter Sealing Material A Depth Depth !'Iller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I # DESTRUCTION I I (No septic system permitted if public sewer is, available within 200 feet.) Installation will some: Residence_ Commercial Other Number of riving units-. Number of bedrooms. ` Character of sod to a depth of 3 feet: CLAY Water table depth SEPTIC TANK. ❑ Type/Mfg P" '" Capacity .49E90 No. Compartments PKG. TREATMENT PLT.❑ t Method of Disposal Distance to nearest: Well' Foundation � � Property Line Z,6a � LEACHING LINE No. A Length of linea g r ..__. Totallength/size FILTER BED ❑ Distance to nearest: Well..ZnffiV. Foundation___ 4 _ Property Line 400 SEEPAGE PITS INK Depth j.4r d Number- SUMPS LI Distance to nearest: Well d�t� Foundation Property Line /Z70 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 regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: 1 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-liws of'Csiifornia.';.Contractor's hiring or suli•contFacting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California," The applicant must call for ail Fsquired inspections. Complete drawing on reverse side.w .. Signed Title: Date: • - - - P .�. ` OR DEP SE ONLY r Y r Application Accepted by - gafe ea Pk 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 O Box 2009, Stkn, CA 95201 INFO A OUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DATE PERMIT NO, . EH 13•71 tREV. i e 51 i'009 iQ© O� L' EM 91.7e I