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oe t APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES � y ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 k` l PERMIT EXPIRES .1YE AR FR Ili DATE S (Com lete in Triplicate) Application ie hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in eotspliance with San Joaquin County Ordinance No. 549 nd 1862 and the Rules and Regulans of San Joaquin County Public Health Services. ulo, Job Address ® �� 7 L/ U City �V Lot Size/Acreage G 1 Owner's Name tLie l��/,P'I C'� Address /4_ — Phone Contractor L�s r!/'____CJ, 1(� Address 4 License No 77XJ- Phone - TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP 1NSTALL'ATION;9�-' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Caain Bornestic/Private }Q'GravoIrPack 0 Tracy Type of Casing_ oel/�,,__ Specifications I'l Public Cl Other F1 Delta De th of Grout Seal `L- I I Irrigation � � p � Type of Grout pprox, Depth I I Eastern Surloce Seal Installed by % n„ Repair Work Done LJ Type of Pump sr1612 H.P. $tate Work Done _ oil-/_L-aePt..- Well Destruction ❑ Well Diameter Sealing Material i Depth" Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is � available within 200 feet.) O Installation will carve; Residence Commercial^� Other f 1 rr Number-of.living units: Number of bedrooms Character of soft to a depth of 3 feet: Water table depth P SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments qj,p PKG. TREATMENT PLT.❑ Method of Disposal F. All Distance to nearest: Well Foundation Property Line LEACHING LINE "' Cl No. 5 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well s, Foundation Property Line `SEEPAGE PITS 1 1) Depth Site Number x SUMPS Ll Distance to nearest: Well i 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 lows, 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 subcontracting 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 componsa- tion laws of California," The applicant must all for a: 064--�")g req 'red inspections. Complete drawing on reverse side. signed f; Title: Date: q- 7- '7 3 * FO DEPARTMENT USE ONLY Application Accepted by Dale Area Pit o�r inspection by - ate Final Inspection 60 Dat Additior4l Comments: 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INfOi ^�CArSH RECEIVED 9Y DATE PERMt7'NO. pj . EH 1Y24 IREV.1/,%5) N �/ 1 2 a� G_�b /�� /-�� j L C� 9=033 L3 EH 14.29 ` ....+ " ' 3"""1 ( 9 -�