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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EMIRES_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 coapliance frith San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1 L City Lot Size/Acreage _ wner's Name Address Phone 1G J r to Nress + ease N/4 0 Phone TYPE OF WELL/PUMP: NEW WUL ❑ WLACEMEDIT Cl DESTRUCTION ❑ Out of Service Kell C1 PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �01_SPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Cl I ustrial 3 0 Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing stic/Private �' ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. D ill ) Eastern Su a Saul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wall Destruction O Well Diameter Sealing Material 4 Depth t Depth Filler Material i Depth ` ' I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitled-if-public sower is j �ayailable within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living;units: Number of bedrooms a _2 Character of soli jo a depth of 3 fast: ---- water table depth `^� V \J SEPTIC TANK ❑ Type/MfgCapacity "^' No. Compartments KG. TREATMENT PLT. C] Method.of Disposal Distance to nearest: Well Foundation Property Line _ , LEACHING LINE ❑ No. b Length of linea Total length/size 7� FILTER BED O Distance to nearest: Weil Foundation�_�Property Line " SEEPAGE PITS t 11 Depth Sire Number ' SUMPS Ll Distance to nearest: Well Foundations Property Line DISPOSAL PONDS Cl t i I hereby certify that�l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and rsgulalions of the San Joaquin County Home owner or licensed agent's signature oartifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subiect to workman's.compensation.laws.o!_Califomia.�Contractor=s hiring.ar-sub contracting signature certifies the wi '' �"� nq: 'I certify that in the performance of the work for which this permit is issued, I shall ornploy persons subject to workman's compenw- tion laws C 'forma.' Thea "$1 ca r uir inspections. Complete drawindor r Signed Titl Date: f. FOR DEPARTMENT USE ONLY Application Accepted by Y Date Area Pit or Grout Inspection by Date Final Inspection by Dat. 1,4 24 9 Additional Comments: el- Ll. X (,ter JVW CAjA124a�(ffl g Applicant -Return all copies to: San Joaquin County Public Health Services i 8nvironmental Health Permit/Services 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201FEE h I • - AMOUNT DUE AMOUNT REMITTED /RE]nCE.IVED BYINFO rASH (� DATE��+I a�1ERM1T'N"n- INEV.trn 5) jqgj EM 112e l� rd } •r L L t D�~�oJ f