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APPLICATION FOR PERMIT ➢ ,ref SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ®� Job Address a 9// - F "'� City Lot Size/Acreage �(? c Owner's Name Address _ E�T Phone 7 5-f_ Contractor Z Address License No.3OS-,721 Phone 96 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing [_l Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications (1 Public EI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION V DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence W-1, Commercial_ Other Number of living units: _L_ Number of bporooms 3 , Character of soil to a depth of 3 feet: C&ell Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 12"o. lla Length of lines S-5 1 Total length/size S FILTER BED ❑ Distance to clearest: Well �f� r Foundation ,ZSL I Property Lina!iL �► SEEPAGE PITS A—Depth t Size s� Number Gl SUMPS LI Distance to nearest: Well I Foundation SO r Property Line DISPOSAL PONDS ❑ 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 A 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: "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 California." The applics caul/for!lA�pactions. Complete drawing on reverse side. �s Signed XXiTitle: uC Cry Date: ARTMENT USE ONLY Application Accepted by e + ��j,�, _ Dats Area Date t or Grout Ins !( / � 5 pectlon by 60ate �- `( Final Inspection by � Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24 IREV.)i n m) / e v� 6� )`ct EH 14-M k ! s Q T?