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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. M is application is made in costpliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ` ?© ye _ -- -- Cit yLot Size/Acreage Owner's Name ��l`r" Y Address ! `S__.!;o 6 e4re— Phone 46 If Y< Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications 1'1 Public 1-1 Other (l Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Soul installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Wall Diameter Sealing Material fr Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION (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 LA SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ `Y 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 parson 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 unify 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." A;P4 applicant at call for I requ, ins , tions. Complete drawing on reverse side. ignsd Tide: —_ 0 u AI&e _ Data: 3 w ^Y OR DEPARTMENT USE ONLY Z9 Application Accepted by �� N 1� O, Data Area b i Pit or Grout Inspection by Date J � Final/Inspection by Date lj 9 Additional Comments: 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 95201FEE ©ZQ g INFO AMOUNT 011E AMOUNT REMITTED CASH RECEIVED BY DATE J_ JPERMIT NO. . EH ]-74(REV.•-a EH t ? 193