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i tpG; 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 (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 /c 3 to/ ilir�kl'S a� Cit ehAe Lot Size/Acreage /0 of C_- Owner's Owner's Nttmee&- Address 7^(/• /Jl9 1 ? Y� Phone Contractor , /^ Address po.��°� lea / Y-License Nao'-(q-3 63 Phone , TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O out,of Service Well O PUMP INSTALLATIONA SYSTEM REPAIR O OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 3 FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS/. - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA�T14N S 0 Industrial WOpen Bottom O Manteca Dia. of Well Excavation r-7 r Dia. of Well Casing f Domestic/Private 0 Gravel Pack n Tracy Type of Casing_ en-1 Specifications -. k ublic acG • [IOther + n Delta Depth of Grout Seal-, -- Type,of rigation ��b f1_Approx. Depth I Eastern Surface Soul Installed by ��j ki l '1 G Repair Work Done U Type of Pump S� H.P. Z= State Work Done_ W90 Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity------ No. Comportments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 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 note employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 111 unities 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 compensa- tion lows of California." The applicant must call for all r uired i spections. Complete drawing on reverse ide. Sig Title: �CC_ tlL t?S Date:-_7L2 _ M."__DEPAR�#AF,NT USE ONLYApplication Accepted by \ Date Area Pit Grout spsctlon by ate Final Inspection by ; "� Additional Comments: Applicant - Return all copies to: San Joaquin Count Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K H ECEIVED BY DATE PERMIT'N0. . Al EH 0-21(REV.I/R 5) EH 162! t