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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEWIT EXPIRES I YEAR MM DTE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made 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 �2" ��T - City Lot Size/Acreage Owner's Name .,t$A2A� LrC'Js1l�l E7Z~ _PRDD,Address _-9-4 e- Phone d�' Contractor L p W�a1� Address—7 hJEAkr?.�1_"A!% - �License No. _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n 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 i CI Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'I Public f� Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by r ) Repair Work Done U ` H.P. Stat*Work'Done Type of Pump Well Destruction ❑ Well Diameter _ Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation vial serve: Residence— Commercial✓/Other Number of living unite Number of bedrooms Character of soli to a depth of 3 fest: I nA,-VjI5 Y CLAS t-OA7-1 Water table depth SEPTIC TANK. ❑ Type/Mfg _44 Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Erf No. 8 Length of lines ` " r p Total length/size I Z FILTER BED ❑ Distance to nearest: Well_ ?KAIJ Foundation Property Line h SEEPAGE PITS l Depth �� -Size i 2_ - Number SUMPS 0'' Distance to nearest: Well Foundation Property tine 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 aito become subject to workman's compensation laws of California." Contractors 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 eompens i- ! tion laws of California." ` r _The applicant must call for all required inspgctions. Complete drawing on reverse side. Signed Title: Date: ZQ ifs - :r , R DEP eTE ONLY Application Aec p by y Date Ar � Pit or Grout Inspection by - -Date LL Final Inspection b Dnts Additional Comments: _ Applicant-.--Return all-copies to: San Joaquin County Public Health Services W T Environmental Health Permit/Services t i 445 N San Joaquin, P O Box 2000, 'Stkn, CA 9520] FEE AMOUNT DVE AMOUNT REMITTED CASH K A RECEIVED SY DA INFO E PERMIT N0. a 3 . EH 13.24 411EV.t/r61 EH 14.26 fi