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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONMENTTTAL HEALTH DIVISION 445 N SAN JOAQU IN, PHONE (209)468-3420 n n cit g a P O BOX 2009, STOCKTON, CA 95201 ru ' PERMIT EXPIRES ] XEM FROM D TE S �ey� 4-% Vk 2 . (Complete in Triplicate) STI { ' Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cos�llance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I QUII�CDt� Job Address I City s/ Lot Size/Acreage Owner's Name (GQ' t 4 Address !fig Phone , I License N �Z Phon Contractor/Yffe 141 t hitt/11 Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Ll STEM REPAIR ❑ OTHER ❑ Monitoring Well PUMP INSTALLATION O SY ❑ DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD. ` PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia; of Well Excavati Dia. of Well Casing t4pomestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other Fl Delta Depth of Grout Sea{ Type of Grout 3f 1 1 irrigation .2-�Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of.Pump H.P. State Work-Done_ Well Destruction ❑ Weft Diameter Sealing Material & Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted if public sewer is 96ailable within 200 feet) [ Imtallstionyvill_serve; _Ras4a ncs --Commercial�....�-Other Number of living units: Number of bedrooms Character of sop to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line } r SEEPAGE PITS I I Depth _ Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the Sen Joaquin county Homs 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 parson in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring OF sub-contracting signature certifies the foNowing: "I esnify 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 Califomia." .:. - r The applicant 4st call for all required inspect' no. Complete drawing on rover" side. SignedTitle: vY Date: T FOR DEPARTMENT USE ONLY Gaai�Application Accepted by Date -5 Area ' { Pit Grou Inspection by Date �• �_.__ Final Inspection by Date Additional Comments: f Applicant.-- Return all copies to: San Joaquin County Public Health Services 1 - Environmental Health Permit/services SanJo 445 N Sae Joaquin, P O Box 2009, t3tke, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. + EN 1}21Ir1EV.1/X51 50 5-3-\-()3 r,`/kms/3- 0q EN 14.28 1! .