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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �1 P 0 BOX 2009, STOCKTON, CA 95201 PERI[I T EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sen 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. t / Job Address 2-k16 �� City Lot Size/Acreage z k%fX Owner's Name �� i j, ® 1 Address .?Z elb �i rf� R 1 12t�y1 Phone 0-Q t � ft[, d Contractor �i S r i�� t Address��k. 1 �y`J:� tr E7 License No��rT 622 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 ,-EF f.4 - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL�•.,A1?_.L OTHER WELLI� PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 16 ('.Domestic/Private tMLraravel Pack ❑ Tracy Type of Casing_ pyo Specifications (1 Public F1 Other n Delta Depth of Grout Seal ® Ty of Grout R I I Irrigation 2ZQ Approx. Depth I I Eastern Surface Seal Installed bv,&"z rr� ruc Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction cP�_ Well Diameter f� Sealing Material i Depth Depth 11: Filler Material i Depth TYPUOF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 sop to a depth of 3 feet: Water table depth (� SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE ❑ No. b Length of lines Total length/size —V, FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "I certify that in the performance of the work for which this permit is issued, 1 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ywot call for all required inspections. Complete drawing on reverse side. Signed X � G ' Title: _ }+°r 11QN Date: FOR DEPARTMENT USE ONLY Application Accepted by WArea Pit Gr t nspection by Date Final Final Inspect��y Date Additional Comments: 421f', o Applicant - Retufn all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 El MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PECK RMIT'NO. . NF EN 1121111Ev.„Mere EN 14•2s