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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 1 YEAR FRPM D TE (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 is casl"liance with San J uin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Hes�th Services. /f//G j,A.4,, City � Lot Size/Acreage .:/ — Job Address Owner's Name l-40 MxIya Address9.: Al of s�'�4r•" afta `3 0 Address ® License No. Phon Contractor 1 TYPE OF WELL/PUMP: I� NEW WEL WELL REPLACEMENT 171 DESTRUCTION clout of Service Well LI (� i Monitoring well, PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Q � DISTANCE TO NEAREST: SEPTIC TANK 116-W SEWER LINES r� / DISPOSAL FLD. PROP. LINE c F06NDATION AGRICULTURE WELW_9 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `r Dia. of Well Excavation ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Casing T of Casing- ' Specifications ' �,Qpmestic/Private C4ravel Pack C7 Tracy Type 9- I'I Public /�1-11�Otthher Cl Delta Depth of Grout Seal Txpe Qf r u I 1 1 Irrigation pprox. Depth I I Eastern Surface Seal Installed by K_6 - Repair Work Done ❑ Type of Pump H.P. State Work Dane ! Sealing Material 4 Depth Well Destruction ❑ Well Diameter uDspi� Filler Material i Depth TYPt OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r` Number of living units: Number of bedrooms Character of goo to a depth'o1 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ .I� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. Ili Length of lines Total length/size n4 CFILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Sire Number „I. SUMPS LI Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS ❑ III I hereby certify that I have propared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner or licensed agents 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-contracting signature canities 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 Caiifornls." 11 y The applicant p4st call for all�squired inspections. Complete drawing on reverse side. 5Signedf tr Title: F Data:.6^23 M&i - FO DEPARTMENT USE ONLY Application Acceptedby Data Area Pit orgro0 Inspection by ry� Date �p Finsi Inspection by Data Z Additional Comments: i Applicant - Return a`ll copies to: San Joaquin County Public Health Services I� Environmental Health Permit/Services I 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 XIA 5 EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. p� . EH 1344 IREv.I/ N sl )NFO i� 0.0t o 3-' 1 iV O EH 14.2E