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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 LID 4-� � 1 ? PERMIT EXPIRES 1 YEAR FROM DATEISSi3EG°J}at'lt F F n' T4 f (Complete in Triplicate) 1'l:r.,h�`TgL'IC 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 cacpllsnce vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Be ices. Job Address _10 �.City Lot Size/Acreage Owner's Name «fy`l�, tS Address l= G�See�r Phone r Contractor Address License No.A21vaS&I Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENTn DESTRUCTION O Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR`Ql OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES lCISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (t, �GQ Domestic/Private O Gravel Pack7 ❑ Tracy Type of Casing_ Specifications �J,\ Il Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation_,w, `Approx. Depth I I Eastern Surface Seal Installed by �J Repair Work Done U Type of Pump H.P. is State Work Done Wen Destruction O Well Diameter 1,40 Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) \O\� Installation will serve; -Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sol to a depth of 3 fest: 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 O No. b Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ` SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 rules and regulations of the San Joaquin county 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 hiring or sub-contracting signature certifies the fo :"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 Iowa o lila." The applic t st call for an r ed inspect' n . Complete drawing on revs s side. Signed Title: MDate: 9 9 , T FOR DEPARTME USE ONLY Application Ace9pted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 6 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 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DAT PERMIT'NO. . z t e,-�_ EH IM24(REV.I/r•51IkE ' l.-wo EH 4.38 J