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k ' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES i XM FROM DATE ISaPBP (Complete in Triplicate) r Application is here made to San Joaquin Count for a 4 � k"Y q y permit to construct and/or install the work herein described. This application is made in cotspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �. OLjftf�0� A-0q City am6aaar"'Et Size/Acreage Owner's Name r CQ.-if' 1 t L_1 _ Address .3r,my q3 Phone T Contractor N LQ Address_$T'`C/U r"21 1 _ License No., 'YJ �t3 Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ <� PUMP INSTALLATION &K— i' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C��7�� Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing [it�' estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications LLLJJJ i'1 Public 1-1 Other' n Delta Depth of Grout Seal Type of Grout r I I Irrigation _Approx. Depth I l Eastern Surf ce Seal installed by Repair Work Done U Type of Pump „ H.P. 14 to State Work Done Well Destruction ❑ Well Diameter Sealing t:erial'h Depth . A Depth F "�'1111er tlater3eil—i�Depth_ — '�.` - -• -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is F " available within 200 feet.) Installation will serve: m _ Residence_ Com ercial F_ Other Number of living units: Number of bedrooms Character of so0 to a depth of 3 feet: ` } Water table depth F SEPTIC TANK'. U Typs/Mfg t / Capacity No. Compartments PKG. TREATMENT PLT.Ll Method of Disposal Distance to nearest: Well Foundation Pr operty Lina v LEACHING LINE 0 No. & Leri th of lines Length Tata) length/size FILTER BED 0, Distance to nearsat: Well Foundation k " Property Line i ft7 SEEPAGE PITS 11 Depth ^ Site IVum'ber SUMPS LI Distance to naiisit:: Well Foundation'Vs" + ; Property Line DISPOSAL PONDS ❑ r 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 C rules,and regulations of the San Joaquin County { Home owner or licensed a nt' ' ges 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 foNowing."I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion Ism of California." The appiieaILL ust call for all required ins tions Complete drawing on re se si Signad X Title: Data: USE ONLY Application Accepted by ,.. � ,, Date _53 a 2-IS SS Pk or Grout Inspection by s Data Final Inspection by Data .. t Addhional Comments: I 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 REMITTEDF�CASH RECEIVED BY DATE PERMiT'ND. . EH 13-24(IIEY.i/A5) V EH 14-28 b - �