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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 with San Joaquin County Ordinance No.'549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / 7 /7 8;&LSA" s 114�' City ' Wt Size/Acreage Owner's Names ► /4 6T Address f'1`D Phone . ) t � 1 Contractor�� Address,-3,5- 01.�7 �e ��icense No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O 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 Cl Industrial O Open Bottom ❑ Manteca =Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout 1 I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. - Stats Work Done_ Well Destruction O Wall Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f STRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) ,i Installation will serve: Residence_ Commercial Other Number of living units: _L_. Number of bedrooms Character of soil to a depth of 3 feet: JL-P `/ 1 Water table depth SEPTIC TANK. O Type/Mfg Capacity 'No. Compartments PKG. TREATMENT PLT.O ; !,.Method of Disposal Distance to nearest: WellFoundation 1 Property,.Line E LEACHING LINE 51--No-& Length of linea 6 3 0 Total length/size FILTER BED ❑ Distance to nearest: Well LOCI Foundation Property Line 1 _ i 1111 SEEPAGE PITS I*depth 5 Sire N 1`,_mber - SUMPS LI Distance to nearest: Well Foundation-� n Property Li e DISPOSAL PONDS O 1 f I hereby certify that I have prepared this application and that the work will be done in accoida_nc'e'with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County,,,,,,,,,,,-„,_,�„ �.„� _ , - _ �1 Z'i . 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 condliss-hp following: "I ce that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compsnsa- tioneisws of 6alifor le." ' T applicant u call for I req itnspec o s. ate, yawing on(lyse side. Sig 'Title: �-�s i'-�! /�_' z�� Date: R DEPARTMENT USE ONLY�� Application Accepted by L Date C�r Z_ Area Pit or Grout Inspection by Date Final Inspection by �� Data -"`Additional comments:` � / t /ort 4([ o riot��J 'f I t ` Applicant - Return all copies to San Joaquin County PubicHealth Services'ppR,�..,,��"" r+r 4 L`1 , Environmental Health Permit/Services JP,"-*t * LNC, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 14-21 1REV.1/$al 4Wc f0 /Z�Z EH 1�-2a v /