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APPLICATION FOR PERMIT 'd SAN JOAQUIN COUNTY PUBLIC' HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUBP I ,cC l�Cp (Complete in Triplicate) Application 1'herelrymade to Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotaitliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. Job Address �Y ' City `g E Lot Size/Acreage Owner's Name . .�e/YV��t�,� Address 'Phone "µ —fir-+% -- -^--,% 1, } i •- 1 ' Contracter ess 1 License No. Phone [ �� r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n.; M DESTRUCTION ❑ Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 'OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL OLD. PROP. LINE [y FOUNDATION AGRICULTURE WELL[, OTHER WELL'S ~.PITS/SUMPS V INTENDED USE TYPE OF WELL PROBLEM AREA CONYrfJCTiON SPECIFICATIONS ' 0 Industrial ❑ Open Bottom ❑ Manteca a. of ell Excavation tDia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing_ Spl et? I ecif c I"i Public Cl Other { n Delta r Depth of Grout Seal g `-. "� Type of Grout X� I I Irrigation —.App(oxr Depth I I Eastern. ,- Surface Seal Installed by Repair Work Done U Type of Pump H.P. I State Work Done Well Destruction O Well Diameter Sealing Material lr Depth i € r r Depth biller Material i Depth-- 30e TYPE OF SEPTIC WORK; NEW INSTALLATION ItT� REPAIRrADDITION I I DESTRUCTION I I INo septics scam y permitted if public sewer is, ? available-wilhin 200 feet.) Installation will some. Residence ZCommercial Otherf f Number of living units: Number of bedrooms Character of soq to a depth of 3 feet: Wats t ble`&pth# i SEPTIC TANK ❑ Type/Mfg °` , Capacity-1 No. Compartments PKG. TREATMENT PLT, ❑ ► t Method of Disposal Distance to nearest: Well J v + Foundation Property Line UI LEACHING LINE ❑ No. b Length.of lines 7 sl lengthlsize FILTER BED '�(� Dis�nce'to nearest. well U� Foundation 2 Property Line { SEEPAGE PITS I I Depth Size Number i SUMPS LI Distance to nee t: WellFoundation Property Line DISPOSAL PONDS ❑ T�� , 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 i rules and regulations of the San Joaquin County;, p Home owner or licensed agent's signature certifies the following; "I certify that in the pertormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subjsct,to\workman's compensation laws of California." Contractor's 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 workmen's compense. tion laws of California." The applicant at call for ell r 'red inspsctlons. Complete drawing on reverse side. Signed Title: Date: J FOR DEPARTMENT USE ONLY a r Application Accepted by Date Area / PIt Grout Inspection by rate �� Final Inspection by �-� Date d y3 Additional Comments.- Applicant omments:Applicant —Return all copies to: San Jokquin County,Public Health Services Environmental-Health Permit/Services 445 N=San Joaquln, P 0 Box 2009, Stkn, OA 95201 FEE. AMOUNT DUE AMOUNT REMITTED -ICCA RECEIVED BY TE PERMiT'NO. I INF fY �j . EM 1]24(11EY.lies) 4 FEN 14.E