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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ! Application is hereby made to S= Joaquin County for a permit to construct and/or install the vork herein described. Thie application is made in coup'liance with San Joaquin County Ordinance No. 5119 and 1862 and the Mules and Regulations of Ban Joaquin County Public Health Services. f �1 tbAddress 17705�/Ty�1€ u. -.-- - -- City T2AC y Lot Size/Acreage wner'a Name �'e 0/4 S Address /6750 �CRr- M a,OI/r 'BL- Phone o 6s6/902 itractor / 61C-# 627 �Address a&G &p 0Ta(1C7 � License No. U phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public l-1 Other Cl Delta Depth of Grout Seal Type of Grout f I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material i Depth 4 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION.I I DESTRUCTI INo septic system permitted if public sewer is ailable within 200 feet.1l installation will some: Residence— Commercial_ Other j Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity u-�• No. Compartments �- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 areby 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 must II r an requ' inspectio11 omplete drawing on reverse side. f Signed Title: —. _ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 14110192 ! Pit or Grout Inspection by Date Final Inspection by Date 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, Stan, CA 95201 M77 AMOU AMOUNT DUE NT REMITTED �yCK RECEIVED BY D/ATE PERMiT'NO. . NFO 13-21[RtlY.i i n al t��IN EM 14•la [