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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESY"' w ENVIRONMENTAL HEALTH DIVISION , P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 11A j f +n� RZMIT EX.R19, 5 1 YEAR PRAM DATE ,I SSU y111R[OW, a (Complete in Triplicate) + r it �'"SIR L HEALTH V Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein describe. This application is made in caatpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 5:JM D L&E M 45%g[%2L)L , City Lot Size/Acreage Owner's Name rAEU 2RA! ,I Address —�5� _- _ __ _ _ Phone Contractor 1^A1u44Z!X TL?�Q&/�—Address cense No.&TjU05?_1a Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./*Y/ PROP. LINE =— Y FOUNDATION AGRICULTURE WELL OTHER WELL�PITS/SUMPS �} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^I F1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing tJ�l LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Ill Other p Delta Depth of Grout Seal Type of Grout r� 0 Irfigation Approx. Depth D Eastern Surface Seal installed by Repair Work Done L3 Type of Pump H.P. State Work-Done Weil Destruction W, Well Diameter Sealing Material i Depth . f&� Depth [� �__ Tiller Material i Depth CENfff= -_-- - �, TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of soil 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 CI No. & Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and.that the work wi3l 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 laws of California." The applic mut 1 f all re i inspgctions. Complete drawing on r9qrse side. — Signed Tide: Date: FO EPARTMENT USE ONLY Application Accepted by DateArea Pit or Grout inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 INFO AMOUNT DUE AMOUNT REN07TE0 CASH RECEIVED BY DATE q �PIERMIT N�Or�] • EH A-M IREV.I/h w 64 �— L_ 1 q ��J EH 73.E