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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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ivow19 4� (Complete in Triplicate) NOSA �:�awSJri�K�tr� Application is hereby made to San Joaquin County for a permit to construct and/or install the work he re dead. "fKis 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. t,/Job Address )0 9 ``Nft�e©n AA) City `� &,gLot Size/Acreage Owner's Name TOt)OZ04' Address «�' �v� s Phone M L16q-'N 45 ✓Contractor�ZI ZI Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public 171 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 _ We# Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONX INo septic system permitted it public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Nu" f living units: Number of bedrooms Character of so th of 3 feet: Water table depth SEPTIC TANK. ❑ Type Capacity No. Compartments PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest. all FaUndaiion Property Line LEACHING LINE ❑ No. 6 Len of lines Total length/size _ FILTER BED ❑ Dist to nearest: Well Foundation Property Line SEEPAGEPITS I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSA NDS ❑ 1, I hereby certify that 1 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 Home owner or licensed agent's signature certifies the following: "1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant 1 fo uire spections. Complete drawing on reverse side. Signed x Title: CL" - Date: :2 FOR DEPARTMENT USE ONLY Application Accepted by _� �, Y_�1pa�� Date V&_, 2-- Area Pit or Grout Inspection by Date Final Inspection by im Date Additional Comments: 17 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 EAMOUNT DUE AMOUN REMITTED CASH ECEIVED 8Y ATE PERMIT'N0. EH U-24 IREV.ti8arEH 14.2!