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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATEISSUED (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 Stade in compliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. 4ob Address .l-RA 0 009 4 #-t 7-r-R AS e - City Lot Size/Acreage �13 710wnar's Name n rs � Address .� �/j�� a��S Phone AContractw IA � ^-I �a." Lm, 12 Address 334 o Q KO'>�'i1_ rl�'- _ License No. a Phone e3f A7g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public la Other fl Delta Depth of Grout Seal Type of Grout Q I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by 01D Repair Work Done U Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation vWl 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 ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. 6 Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 lawa of Califomie." A/The applicant mu call for all insp+ctions. Complete drawing on reverse side. �,1(Signad Title: Date: rte ' \ FOR DEPARTMENT USE ONLY Application Accepted by �-a— Date Area Pit or Grout Inspection by Date Final Inspection by YZ" Data 10/1 T/4Z2-- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Heal Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE IN WO FO DHE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. . EN 13.24(REV.+iest �II�V (p p `p '� Q C_�U !�ZIb `l� ZOt� EH 14-M