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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH_ DIVISION # 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 1891110 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made is compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �>7 S'T 03 f,6111-or U1,4 y A401jC p6sr LriDE o e' A City S-ZeK-*N t Size/Acre e Job Address (,�,RoKN.11W.f TE2 O(,Q�J • ;;11/$q � / Owner's Name L� 4�� CORP, Address 10$7 1 �D lI! Phone a 3g t si �� ►a��ga� Contractor P 17CAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of Service well LI -PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i DISTANCE TO NEAREST: SEPTIC TANK M SEWER LINES &_/9 - DISPOSAL FLO. PROP. LINE FOUNDATION* Lt_ AGRICULTURE WELL Mh OTHER WELL Spa PITS/SUMPS/L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `r Dia. of Well Casing A 0 Domestic/Private V4 Gravel Pack; ❑ Tracy Type of Casing__ a• yd _�� Specifications' !'I Public Cl Other i 1-1 Delta Depth of Grout Seat A-311 Type of Grout o 7 1 ✓© I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by -T,-f-W P��e uwrR+s Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter f wing Material i Depth Depth hiller Material i Depth ' v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is j U available within 200 feet.l Installation will serve: Residence_ Commercial T Other �^ Number of living units: Number of bedrooms _ Character of sag to a depth of 3.feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑T No. i length of lines Total length/size - FILTER BED _0- Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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"N employ persons subject to workman's compensa- tion laws of California." The applicant must call for allrequired inspections. Complete drawing on reverse side. Signed Title: 66-IS y. J�44- Date: r �� D_/7 -7Q- FOR DEPARTMIE*USE OiYLY �a � Application Accepted by Date Area Pit or Grout Inspection by Date f 2''? g Final Inspection by Date Z , Additional Comments: - t Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ;. 445 N San Joaquin, P O Box 20 , kn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH R ED BY DATE PERMIT NO. INFOAmu G a . 0 EH1744IREV.$In51 �� f %� 1�� EH 14.10 i`