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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 9520) PERMIT EMIRES 1 YEAR FROM DATE__I8SUED (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 compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules andL Regulations of San Joaquin County Public Health Services. f/ Cit �� ', Lot Size/Acreage ,A Job Address �_ .—._ it Y I Owner's Name dress 13A445 Phone S C r -OZ 3 (`` Contractor 61 Address , `-o��` r sJ License fVo � �f3� `�� 73oJ Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION W' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANKS,f� _ SEWER LINES DISPOSAL FLD.--22 PROP, LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tri Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation^ Dia. of Well Casing >d'DomasticlPrivate T Gravel Pack — ❑ Tracy -Type of Casing /! Specifications I'1 Public I=1 Other fl Delta Depth of Grout Seal Type of Grout. << I I Irrigation -L-a- .Approx. Depthlyaatern Surface Seal Installed by cati A Repair Work Done U Type of Pump S(�'/S H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADOITI N I I DESTRUCTION i I INo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence— Commercial Ot er Number of living units. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK. O Type/Mfg Capacity No. Compartments L �I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well .Eoundation Property Line LEACHING LINE L1 No. fir Length of lines a Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size ,4Y Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l 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 n] rules and regulations of the San Joaquin County ( " Home owner or licensed agent's signature certifies the following; "I certify thatyin 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 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 GO for alt required /inspections. Complete drawing on reverse side. f Signed?(_ //%�►-1'�t- •.,.,_._.. Title: Date: DEPARTMENT USE ONLY Application ecapted by t Date Area Pit r Grout spection by Dat Final Inspection b .° Detti _ Additlonaf Comments: ; Applicant - Return all copies to: San Joaquin County Public Health,Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT'NO• ; EH 13-24(REV.Iiea) Wryp® (�