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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES -1 YEAR FROM DATE ,ISSUED (Complete iu Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is [Wade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name IS m a �T•�� , : Address Phone r Contractor AddressLicense No.L��Phone d sta TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 n Industrial ❑ Open Bottom M Manteca Dia. of Well Excavation Dia, of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications O I'1 Public I:1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION STRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: R 'dance�ommerciel Other Number of living units: r Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Lento. & Length of lines/— Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS ILI,-�Depth Sire g�Nusrtber SUMPS Ll Distance to nearest: Well Foundation- L�� Property Line DISPOSAL PONDS ` D 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 comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- 6 n f California." The applicant sl II for II quir ins c ons. C m ing on r rse side. Signed _ Date: FOREPARTM ENT USE ONLY Application Accepted by (-, �� . �, �^Vic, Date 3 Q` Area _ Pit or Grout Inspection by Date Final Inspection by J A 1. Data Additional Comments: Applicant - Return ell copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. EH f EH 14.26114EV.1/05) 0 -1 coo C7 l� -- I / 4 r 7 / 7 tJ C(6—oqs