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F I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YF AR 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 corspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sass Joaquin County Publio Health Services. Job Address Tragy 81 Y a CiXyTrq-c IZZ Lot size/Acreage Owner's Name �'��toca r� �1u5��11 _ — Address C� v Phone 07r s A06 Contractor v Address J• I License No.3�l ��01 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION XDut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE {r^ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v' f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` [1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I') Public rl Other n Delta Depth of Grout Seal Type of Grout t J I I Irrigation ._,._Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H,P. S�atq Work Done C Well Destruction ❑ Well Diameter Sealing Material A Depth f✓i � Depth 155 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) l Installation will serve: Residence— Commercial— Other i Number of living units: Number of bedrooms Character of soil 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 t LEACHING LINE CI No. ✓4 Length of lines Total length/size ' f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to dearest: 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 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." Contractors hiring or sub-contracting 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 st call for Iu,qq 'ed inspections. Complete drawing on r v,roeQsidde. q• Signed Title: � Z - ---- -- Date: 1 � R DEPARTMENT USE ONLY Application Accepted by Date Area ..... Pit of Grout Inspection by Date Final Inspection by Date !� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San+Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK If RECEIVED BY DATE PERMIT NO. INFO (CA�S7H(� �y I-IS //�EM 14-M EV.r/�61 �,�Q ..,G bTJU 3-1 t�� —6 EM li•7e