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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON1dENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP I RES 1 YEAR FRQM DATE 19JSUED (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 with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jatr Address _ r MdZ �r Cit we Lot Size/Acreage A-eAC� r Owner's Name �� f �' L- Address ` Phone r�. r 111 V. ��/� /[f� / [ 3r91K2Z& Phone 6 S d 5 ConErac '%� Address,_,�..,< < License No. � �' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "" DISPOSAL FLD. PROP. LINE —FOUNDATION AGRICULTURE WELL- - bTHER WELL ^ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation } Dia. of Well Casin Is C 11 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ i Spr l i I1 Public Cl Other 171 Delta Depth of Grout Seal ; Ty�+ �I�k�►1 � I I IrrioalionApprox. Depth I I Eastern Surface Seal Installed by ~+� Repair Work Done ❑ Type of Pump H.P. State Work Done JUN Well Destruction 0 Well Diameter Sealing Material i Depth 1N CoUN.Y Depth Filler Material i Depth __�,u��('.u> ALTH SEWC� ES TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I i INo septic[r, public sewer is available within 200 leet.l Installation will serve: Residence Commercial-___ Other / Number of living units,, j Number of ooms Character of twit to a depth of 3 feet: ._ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Ll Method of Disposal 04tanee to nearest: Well Foundation Property Line LEACHING LINE No. 8 Length of lines Total length/size 0 x FILTER BED ❑ Distance to nearest: Well foundation 140 Property Line s 11 SEEPAGE PITS DepthSi:e Nrumber / SUMPS _ Ll . Distance tonearest: Well Foundation _e _ _ � Property Line DISPOSAL PONDS ❑ 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 laws of California." The applicentcall for u' inspections. Complete drawing on reverse side._ a 7 Signed Title:0 ___ Date: J FOR DEPARTMENT USE ONLY Application Accepted by Date3 tL,I�le Area � 1 Z 7 Pi r Grout Inspection by �.�� pate G � Final-lnripeetion by 'lforl+lGe�s�sf' Date Additional Comments: d 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 95261 +' INFO AMOUNT DUE AMOUNT REMITTED CASH .-RRECEIVED By /D/ATE IV-1a PERMIT'NO. EHsi26tREV.Ii n ✓ V! (9 ,�