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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 San Josquin.County for a permit to construct and/or install the Work herein described. This application is made in eampliance with San Joaquin County Ordinance Ho. 549 and 1662 and the Rules and Regulations of San Joaquin County�Pjubbllic Health Services. 4 ,/Job Address Q V c 5 -5 -1 A A City Lot Size/Acreage ✓Owner's Name' l H' t Address �COdM1 S ,' f/1 (d of rf- Phone r Contractor- S�F_ Address - License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ out or Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Weil 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 D Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done V Type of Pump H.P. State Work Done_ Wall Destruction D Wall Diameter Sealing Material i Depth . . Depth biller Material S Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION ( I DESTRUCTION INo septic system permitted it public sewer is vailable within 200 feet.) Installation will some: Residence— Commercial Other I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. 6 Length of lines Total length/sire I FILTER BED D Distance to nearest. Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Homo 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature cartifies 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 Califomle." The applicant st call for all req ired insPections. Complete drawing on reverse side. !,Signed Title: '�' "K� _._ Date: FOR DEPARTMENT USE ONLY Application Accepted bye.. _ Date Z ^L Area a Pit or Grout Inewflon by Date Final Inspection ti . 4 Additional Comments: e Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 FEE{ INFO AMOUNT DUE AMOU REMITTED K H RECEIVED BY DA PERMIT'NO. • 01 EH 13-14IREV. 7L / �.. EH 14.10 9 'a�