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i 'T t APPLICATION FOR PERMIT A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION. ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P 'O BO%.20091 STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE •I9SUFD (Complete ,in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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 Address 'ZO d City Lot Size/Acreage Z P C Owner's Name ' e, Address a rn Phone 3 P` 17/ ContractoritsC "Addreii'- a /8 Ilk _-_ License N07 27 Phone 73 TYPE OF WELL/PUMP: NEW WELL X ``WELLREPCAtEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ` PUMP INSTALLATIONS SYSTEM REPAIR Cl y OTHER O Monitoring Well l7 DISTANCE TO NEAREST: SEPTIC TANK LOet SEWEff LINESDISPOSAL FLD.1$� PROP. LINE FOUNDATION AGRICULTURE WELL , a HT ER-WELL PITS/SUMP'S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; 0 industrial ❑ Open Bottom O Manteca Dia. of Well Excavation I L Dia. of Well Casing 19I DomesticlPrivate Gravel Pack n Tracy _-Type of Casing_ K Specifications, r`y 1'1 Public n Other n Delta Depth of Grout Seal Ian �Type of Grout„ t�`r I I Irrigation ZCP--Approx, Depth I I EasternSurface Seafc- rinsialled by ipP-7x--A _ Repair Work Done L3 Type of Pump Sy H.P. 3 ~� r State Work Done Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION i I DESTRUCTION I l lNo 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 salt 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 Lina LEACHING LINE El No, 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line - l SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina - DISPOSAL PONDS ❑ d 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 'e' + Homs 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 hifing or sub-contracting signature certifies the following: "1 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 Callfornla." The applicant must all for required inspection*, Complete drawing on reverse side. (, q Signed �l_��iG'�. __. Title: __ C�_[/�//VE� Date: R DEPARTMENT USE ONLY i Application Accepted by Date Area 22. Pit orr t Inspection by Date f a Final inspection by Date :l Additional Comments: _... -, _ - �� ._ _�.. y �_ . y. �._ _ - _.._ •.-,. ____.__. Applicant - Return all copies to: San Joaquin County Public Health°,Seivices Environmental Health .permit/Serv'ices t :'�� 1 445 H San Joaquin, P O:Box 2009, Stkn, CA 95201 i FEE�/ AMOUNT DUE AMOUNT REMITTED K _,RECEIVED BY ATE PERMW NO. em M24 IRIV. i nab EH /y ib7a r j