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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \k ENVIRONMENTAL HEALTH DIVISION _\ 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. �w.tL1�► Lot Size/Acreage Job Address i _ _� City Owner's Name"��5E�� erred ss --1 egJi-�� ^ Phone Contractor Address t license No. _Phone g-1L tom' TYPE OF WELL/CPU NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public 1"1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern urface Seal Installed by vva Repair Work Done VJ Type of Pump dam!• H.P. :1 a State Wgrk Done Well Destruction ❑ Well Diameter Sealing Material Z Depth r-*" -7 Y.ITW Depth Filler Material i Depth �� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 soli to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. nts PKG. TREATMENT PLT.❑ Met Distance to nearest: Well Foundation Property UR Fn�� r+irF'1f'f p LEACHING LINE ❑ No. b Length of lines Total length/szpe FILTER BED ❑ Distance to nearest: Well Foundation ProorlGfLl,i��pQUIN COUNTY t'Uti Ili H��i1.TFl RVICES SEEPAGE PITS 11 Depth Size Number IL) d SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 persons subject to workman's compensa- tion laws of California." The applicantMust call for al cared inspections. Complete drawing on reverse aside. I ' ,� / Signed X RAJ a Title: _ y�Y [s Date: `� —s—�. FOR A USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dated Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO EEE AMOU�N,TT DUE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT'N0. . W Y Z� EM 17.71(REV.r M 51�►( �,v`� rI ., EN 14.76 , ` V