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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 O 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address e" � 'I !7/ C�I%_ �FC"O'er- ity ' T Lot Size/Acreage Owner's Name R f ch `kA."`address / �[ -!��(� r _ -_�'� Phone YZ 6 -66 66 Contractor L1 -ISO` ,1P Address 172 G46_7, ICE A2� License No. , d f `� Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTA DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑.. . - SYSTEM REPAIR 0 OTHER ❑ Monitoring Well (7] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES dam` DISPOSAL FLD. ---^--PROP. LINE FOUNDATION `""'� ' AGRICULTURE WELL -LELL WELL PITS/SUMPS— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ®-flpen Bottom ❑ Manteca. Dia. of Well ExcavaiiDia. of Well Casing R f.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 2s Specifications _ V] Public Cl Other fl Delta Depth of Grout Seal Type of Grout A-41juation 61D Approx. Depth I I Eastern Surface Seal Installed by y Repair Work Done 0 Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material i Depth Depth ]tiller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I] (No septic system permitted if public sewer is ' f available within 200 feet.) Installation will serve: Residence__._ Commercial_ Other Number of living units: Number of bedrooms Character of$all to a depth o able depth SEPTIC;TANK. © Type/Miq Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal JQ Distance to nearest: Well oundation - Property Line ` LEACHING LINE ❑ No. 8 Length of Total length/size q FILTER 9ED ❑ Dist an rest: Weil Foundation Property Lineff SEEPAGE PIT!"�< Depth Size Number I SUMPSDistance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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 Sen 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 compenss- ' tion Iowa of California." The applicant mut call foralt .equir insPections. Complete drawing on reverse '"e. 4 v Signed Title: Date: FOR DEPARTMENT USE ONLYAL .Application Accepted by Date -2—Area PitGra't nspectio_n by Data /41--Final spection by Data Additional Comn+erita: 6 �� wt Applicant, - Return all-copies,to:,, San Joaquin County Public Health Services O ulfA 50"a4o t;w tf�• ",kk -Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INF AMOUNT DUE AMOUNT REMfTTED ASH CK RECEIVED BY DATE PERMtT N0. ?100 t _ - . SH 1}2t liltti,1/01M & m ')D EH 11• �(