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APPLICATION FOR PERMITS " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES_1 -Y_EAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sart Joaquin County.Public Health Services. .,"Job Address � � � L � . �O S&V,-r,—,L:T 5-1, City 1a Aa_t Size/Acreage _L,92 X- Owner's Name ' Address f `t Phone. 'r Contractor Address s ' ' License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy' Type of Casing_ Specifications 1'I Public EI Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter-, Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIWADDITION t E77W septic system perm if public sower is ilable within t.) Is will serve: Residence_ Commercial— Other Number of livin Number of bedrooms Character of aaii to a depth set: t Water table depth SEPTIC TANK. ❑ Type/Mfg city No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: WeIIFoundation Property Lina LEACHING LINE 0 Nc. i Length nes th/size FILTER BED Q Dista o nearest: Well Foundation Propert SEEPAGE PITS i I Depth Size' Number SUMPS Ll Distance to nearest: Well Foundation Property Lina DI AL 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 Homs owner or licensed agent's signature cenifies 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 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 all for an required ' aptict' n Com tate drawing on reverse side. SWr+d Title: _ Date: FOR EP ONLY Application Accepted by Data—5'~1O 172% ___ Area ' Pit or Grout Inst action by Oats Final Inspection by Data ^�v a t7i Additional Comments: t cicd - ` Applicant - Return allicopies to: San Joaquin County Public Health Services Environmental Health Permit/Services 1n w *W See,. 445 N San Joaquin, P 0 Box-2009, Stkn, CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTED] CASH RECEIVED BY OATE PERMIT'N0. EM13-24 IREV.I ION si �/j /p� 9 EM t62a