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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES —= ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 a(� P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSIJ& (Complete in Triplicate) 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J� / Job Address 2F�3�j t'�EE64 Tt�Q City Lot Size/Acreage 2• Owner's Name 'PA()LA R 1& E Address 03] IV- 6L- Phone 13 1 1L7- Contractor QWIU _ _Address Address SrT�G License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitors Well ❑ Lot I /17r- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE �/ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -_XAAI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A-&- wCLL ❑ Industrial. ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing [1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public l l Other r - fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal installed by Repair Work Done LJ Type of Pump H.P. _._ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Mateifal i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 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 soR to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfo Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Toial length/size 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 ❑ l 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, 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 persons subject to workman's compensa- t*n laws o 'ornia." The a ant ust call to all r ired ins ctions. Complete drawing on reverse side. Sig Title: It-f- 7!7 - _.. D /22 ate: I FOR DEPARTMENT USE ONLY Application Accepted by i Date !� Z— Area I!!Pit or Grout Inspection by data Final Inspection by Date f7 IT, 'Additional Comments: ltJ 6U-:1 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 INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY TE PERMIT'N0. • EH 13.211(REV.i i n {H 14•211 / '�