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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT _EXPIRES 1 YEAR FROM DATE IS§M (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccwt liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health /!Services. Jab Address City 4/AA0 ZA/ Lot Size creage O Owner's Name — v"J Address $'.�rs7E Phone 7 A)-4 p4EX4,FiG7— Contractor FtOYE� Address--s-l�Af 95x1.r_ _ __ License No. Phone 116C-3971 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O 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 C) Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ._.,Specifications 11 Public Cl Other f'1 Delta Depth of Grout Seal Type of Grout z 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P, State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth _ Depth— Filler Material A Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l'I (No septic-system-permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other F Number of living units: —L-- Number of bedrooms I Character of soil to a depth of 3 feet:_.S-A ALp�/ Water table depth SEPTIC TANK. ❑ Type/Mfg --P*L, Capacity L 2=eJwf - T No. Compartments le PKG. TREATMENT PLT.❑ r Method of Disposal Distance. to nearest: Well Foundation !i�g Property Line .St9 LEACHING LINE No, 8 Length of lines __�'"' Total length/size FILTER BED ❑ Distance to nearest: Well SAS Foundation Loo Property Line SEEPAGE PITS I 1K Depth Size_ Number E �— SUMPS LI Distance to neares � t: Well _- Foundation 70r" -. Prop6rty Lina � ' 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: "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 sub•contrscting 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 all required in ctions. Complete drawing on reverse side. SWC Title: F r Date: FOR DEPARTMENT USE ONLY Application Accepted by Date + �Area r or Grout Inspection by Date�. Final Inspection by „• jDat4�� Additional Comments: f Applicant .- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/5ervieee 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED M1 CASH RECEIIVVf D BY DATE PERMIT'NO. . EH*24(REV.1iti51 •� 1 r� ,,,3! / EH 14-S