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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 DATE ISSUED (Qomplete 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressCity Lot Size/Acreage !► /� mgll ? AFT37 ) Owner'sa+lame � t r/ SAddress i � Phone ~" �� 04 Zo Contractor Address ,+/ 21 •/sflL4jQO2 License No. ?46 Phone TYPE Of WELL/PUMP: EW WELL C t WELL REPLACEMENT 17.7 DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION,C1 1. SYSTEM RERAIR 0 'OTHER 0 14onitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK /Oh -SEWER LINES ` � DISPOSAL FLD. PROP. LINE LiL FOUNDATION �- AGRICULTURE WELL -�f OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` f C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing (A Domestic/Private ravel Pack ❑ Tracy Type of Casing_ Tri/� tSpecifications I'1 Public (_1 Other ", ' ""^f� Delta ""°"''# Depth of Grout SeaF-- - �_ Type of Grout � A � I I Irrigation 7�� a�r�.Approx.'D'pth I I Easterq ace Seai Installed by � �f� -Zwj��AlA. Repair Work Do 0 Type of Pump wo. State Work Done, Well Destruction ❑ Well Diameter - Sealing Material i Depth f Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 111No 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 loll to a depth of 3 feet: Water table depth \ SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PGT.❑ Method of Disposal - Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size � FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Deptfi Size ^ Number SUMPS LI Distance to nearest: Well Foundation 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 rulas and regulation of the San Joaquin County ' Home owner or licensed agent's signature eenifies the following: "I certify that in the'p rformance 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 cartify that in the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant dTrequ' t Ms.�Complets�drawing on rave ae e. . Signed Title: ^ `� Date: ' If FOR DEPARTMENT USE ONL Application Accepted by Date ` Area // Pit rout speetion by Date / 4 Final Inspection by Date _ Additional Comments:, /� C -70-135- Applicant ? IApplicant - Return all copies to: Ban Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009•, Stkn, CA 95201 F fE AMOUNT tlE AMOUNT REMITTED CASH RECEIVED BY DATE EPERMIT'NO. EH 13.74 IREY.li r a!EH 14-2e f , Dv o �I