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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCBTON, CA 95201 (209) 468-3447 PERMIT EXPIRRS 1 YEAR PROM DATE ISSUED (Complete in Triplicate) (o-7 �( 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 ccupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San J blic Health S rvices. Joaquin Co t Pt 1 oaq uq`eN i"� c4Ct-�� s 15 o s. " wa: Job Address f� 3 5` f vrfi City— Lot Size/Acreage Owner's Name tom) Address ' Z�(X�� .U1 Id�CUPhone Contractor LAM ►'�Ie l Address 25 E� 1t� License No SID-NoPhone —aqs �t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (2,5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRBFI-610 0-30 FOUNDATION AGRICULTURE WELL OTHER WELL MTS7S09v*6 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial O Open Bottom ❑ Manteca Dia. of Well-£xeov"ian it g U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Cag �^a * Public 11 Other O Delta Depth of �e'5eel 10 '30 CI Irrigation Approx. Depth C] Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material ` Depth e �. Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No 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 soil to a depth of 3 feet: Water table depth W SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 tom, rules and regulations of the San Joaquin County V 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 subcontracting 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 applicant at call for 11 r quir d inspections. Complete drawing on reverse side. G} Signed Title: sDate: 6 6C3L, FO DE RTMENT USE ONLY d- ��- - Application Accepted by Date res Pit or Grout Inspection by Date Final Inspection Date`' _1 Additional Comments: �( �s Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O B 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. . EH 13.24(REV.I/M 5) EH 1446