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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .= ENV I RON1dENTAL HEALTH DIVISION N SAN JOAQUIN, PHONE (209)468-3420 .y r P O BOX 2009, STOC%TON, CA 95201 i PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) Application is hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in comiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ob Address _,Zzf,g,_ l� �� f PIS' City Lot Size/Acreagel?0 �(Owner's Name N 12m Ja�� ✓- t1,Qh S Address Phone.319 0 6-VIT ,Contractor 1 s kd Chi eC Address License No. Ga Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,n DESTRUCTION Ll Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR JAY �HEA�O Monitoring Well ❑ '`C�Cas Sti,�.wt .aE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'r a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS 0 Industrial 11Open Bottom ❑ Manteca Dia. of We1l'Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ITPubiic 171 Olher n Delta Depth of Grout Seal Type of Grout I I Irrigation ,_,._.Approx. Depth 14 Eastern Surface Seal Installed by t� Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material A Depth Depth Tiller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is � v available within 200 feet.) i Installation will sena: Residence_ Commercial_ Other l Number of living units: Number of bedrooms "A { Character of soil to a depth of 3 feat: l v Water table depth SEPTIC TANK ❑ Type/Mf g Capacity No. Compartments .� PKG. TREATMENT PLT. ❑ ' u s hMethod of Disposal Distance to nearest:' Well Foundation Property Line t LEACHING LINE CI No. i Length of lines Total length/size i FILTER BED ❑ Distance to nearest:" Weil _ - Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ Ic I 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for MI required inspections. Complete drawing on reverse side. f Signed Title: ZZ. 1�p Date: 2 ENT.USE ONLY Application Accepted by _[� _ »r>oGDate ° Area Pit or Grout Inspection by Date Final Inspection by Additional Comments, l 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 FEEINFO AMOUNT DUE AMOUNT REMITTED /C x RECEIVED BY GATE PERMIT'N0. . EH 16 I RFv, i w s i / '�� `06.11 EH1446 }