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�i APPLICATION FOR PERI!I T 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 FROLI DATE ISSUED (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. Job Address _ a S 7 97/ City Lot Size/Acreage P Owner's Name Address ��nA � _ Phone _ zoo Contractor ddress, /�i(1-EWAJdg�-/34de�P1 License No�� . _Phone '40.5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring We11 ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing P-15"mestic/Private KGravel Pack7 ❑ Tracy Type of Casing—_F_90 Elm— Specifications 1.1 Public [I Other (l Delta Depth of Grout Seal ? - - -- Type of Grout ''? I I Irrigation —.Approx. Depth Ifastern Surface Sedi Installed by Repair Work Done 0 Type of Pump .` H.P. aL l_ State Work Done _ Wall Destruction O Well Diameter Sealing Material i Depth Depth !'filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION i I DESTRUCTION I I (No septic system permitted if public Bawer is available within 200 feet.) Installation will some: 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 Distance to nearest: Well Foundation PropertyRA � R609129-93 LEACHING LINE ❑ No. 6 Length of lines Toral length/s' 0 991L FILTER BED ❑ Distance to nearest: Well Foundation Props 1 e SAbJ U IN l;i.l;, !V SEEPAGE PITS 11 Depth Size Nu,t,,PUBLIC HF-AL `. SUMPS LI Distance to nearest: Well Foundation �'Plr 1ne 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, antf 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 of sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's Compensa- tion laws of California." The applics must call for MI required inspections. Complete drawing on reverse side. Signed Ze4a ee;z��01� Title: .Ilr�. ��A�� e Date: F DEPAR Application Accepted by Data a Ph or Grout Inspection by Date Final Inspection by Date Additional Commenw Applicant - Return all copies to: San Joaqui County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE k AMOUNT REMITTED CEiVED l3Y TE PERM17'No. INFO CA l . EM t}44 f11Ev.1 i n EH 11.2e