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APPLICATION FOR PERMIT � �( SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES { {�! ENVIRONMENTAL HEALTH DIVISION I 445 N SAN JOAQUIN, PHONE (209)468-8420 P O BOX 2009, STOCKTON, CA 95201 PEIi� T_EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j Application is hereby made to San Joaquin County for &-permit to construct and/or install the work herein described. This I i I application is made in ceelpllance vith Ban Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /` Job Address4C. C/R. W`'' City Lot Size/Acreage s Address �r'r'/ " Phone Owner's Name actor '�-7 � C n r G /n 5 Address License No,3�W;f Phone 33 4# �ys w o t a F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5e DESTRUCTION Out of Service Well ❑ -" PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.15*0 PROP. LINE -46L 3 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , 0 Industrial ❑ Open Bottom ❑ Manteca Die. of WellExcavation Dia. of Well Casing ' )eDomestic/Private Gravel PackC7 Tracy Type of Casing_ /0�G Specifications Il Public Ia Other fl Delta Depth of Grout Seal Type of Grout C C^6'Y' I I Irrigation 'L Approx. Depth I I Eastern Su(faas Seal Installed by C9�`-'`T4A-04 — f Repair Work Done 0 Type of Pump S� H.P. ��'.,,_; _� Statss Work Done X2L' r7�GL� Well Destruction well Diameter. 6 » Sealing Material i Depth Depth Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 1,1 INo septic system permitted it public sewer is available within 200 feet.) s Installation will serve: ResidenceK Commercial— Other Number of living units: Number of bedrooms i 1 Character of Goll to a depth of 3 fest: '� Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT.❑ s Method of Disposal C Distance to nearest: Well - Foundation Property Line s LEACHING LINE ❑ No. &'Length of lines ; Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE-PITS{ I I Depth Size Number SUMPS Cl Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS Cl 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 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 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 persona subject to workman's compensa- - tion laws of California." The applicant ntust all f all r )rad inspections. Complete drawing on reverse side. Signed _ Title: ,A— ^- Data: FOR DEPARTMENT USE ONLYlz�lrr Application Accepted by o Date �� —Ci2 Area 4 Pit or Grow nspaetion by Date d '� "- Final Inspection by Q! Additional Comments: � . Applicant - Return all copies to: San J aquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IN AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By DATE PERM17'NO. . EH 1}21(RIY.1/115) WD (]f� 4 ✓ S �V t �Z—� 2 EH 11.2E I 7 1 �/v r Q� of �L � zgs9