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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES-1-YKJAR FROM DATE ISSIJBP (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 ceopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address '�L�� , _ ee4Tp R.4City �Scr`'L-74- Lot Size/Acreage Owner's Name Toh& Address Phone f Contractor rho 4 50ry Address GWS JL ve ITZ U� . License No.y`�f� 857/ Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE-- FOUNDATION INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ;�� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial _ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Cl Domestic/Private ❑ Gravel_Pack ❑ Tracy Type of Casing_ Specifications. - l'I Public Cl Other b" fl Deity Depth of Grout Seal Type of Grout tel` I I.Irrigation -!z:-__.Approx. Depth I I Eastern Surface Seal Installed by \��\ Repair Work Done U Type of Pump H,P. Stats Work Done _ Well Destruction ❑ " Well Diameters Sealing Naterial i Depth v? i Depth -_ ]Killer Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence Commercial— Other Number of living unite: �_ �Number ofbedrooms Character of soli to a depth of 3 feet: _A012 1UAI - _ t. _Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No: Compartments PKG. TREATMENT PLT.L1 "` 1 Method of Disposal Distance to nsorest: Well Foundation Property Line O LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distances to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth -Size �7_ Number 1 . SUMPS Al Distance to nearest: Well 00 Foundation T 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 ordinanceti:state laws, an d 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 compenss- ` tion laws of California." r The applicant mu Coil for all required inspections. Complete drawing on reverse side. t Signed Title: Date: ' T`q L x t - FOR ARTME USE ONLY s t _ . w Application Accepted by " Dats Ar ` or Grout Inspection by J Dater' '" Final Inspection Additionoi Comments: µ � F e Applicant,--8eturn all copies_to ~San Joaquin County Public Health Services ` Environmental Health Permit/Services ` - 445-N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEEACK MOUNT DUE AMOUNT.REMtTTED I <IRECEIVEDY IN D TE PERMIT NO • EH 13.24{REV.�ihSlY-� FN ta•2s