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i APPLICATION FOR PERMIT SAN JOAQUIN. COUNTY PUBLIC HEALTH SERVICES PA Y � I ENVIRONMENTAL HEALTH DIVISION a' " -445 N SAN JOA QUIN, PHONE (209)468-3420 �EC ,�� P O BOX 2009, STOCKTON, CA 95201 Q 0 T 2 03 S'"'J04Quip� -PERM EXPIRES Y FROM DATE L1C yca4 (Complete in Triplicate) MENTALLr�SER� 'JCES HEALTy U -y Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri11142N This i application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of,San Joaquin County Public Health Services. Job Address � 1\1 Vv�1"! City c )tC 1__f�lt�{V _ Lot Size/Acreage (J 1Ir k Owner's Name� '"� 7- OIL_ l „ Address k Phone �+ to Contractor VV I_ R ZW Address f( RZO SLicense No. 521-999 _ PhonekY, TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP iNSTALLATION,o INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES r DISPOSAL FLD. PROP. LINE ' FOUNDATIONAGRICULTURE WELL' OTHER WELL ! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s � 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lam" Dia. of Well Casing �1 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ PtIL- Specifications H�-OL�_l 40 I.1 Public f l 01her h (l Delta Depth of Grout Seal [3' - Type of Grout SAA) � I I Irrigation —.Approxi Depth I I Eastern Surface Seal Installed by VJE5T 14A?.Ifs7 Repair Work Done 0 Type of Pumpt H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material a Depth N MOtSCtDArrs6 G tiJ• Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is + available within 200 feet.) f Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms " Character of will to,a depth of 3 feet: Water table depth SEPTIC TANK p TypeJMfg ICapacity No. Compartments PKG. TREATMENT PLT.Cl \ Method of Disposal. M Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑, Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth'. _t Size Number '- SUMPS Ll. .Distance to nearest Well Foundation Property Line - _ -DISPOSAL PONDS 0 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."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 Iowa of California." The applicantt call r uired inspections. Complete drawing on reverse side, r . Signed Title: L{.`E& oril�'{x.NTA L A FFA i e S Date: (0 1 f 9� _ FOR DEPARTMENT USE ONLY Application Accepted by. Date 10 Z 3 Pit or Grout Inspection byDate y/ i�� Final Inspection by Data Additional Comments: 1 Applicant - Return all�copies`to San Joaquin4County`Public Health-Services' Environmental Health Permit/Services ^ o 445 N San,Joaquin, P 0 Box-2009,.Stkn, CA 95201 FEE INFO AMOUNT DUE -+ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13.24(REV.I/it 6) -/7- FN u.zs I