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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 i PERMIT EXPIRES 1 YEAR FROM DATE 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 conpliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address --- Cit Lot Size/Acreage f / c, Owner's Name Address 5 E` one .�3 ` EI Contracto 6 Mk Addressf License Nqg r � 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 IAWI f SEWER LINES Me4 DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing w4pmestic/Private Gravel Pack7 ❑ Tracy Type of Casing- Specifications i 11 Public 1_10 /j / Fl Delta - Depth of Grout Seal ..1�lfC�4_- T of Grout �11_ 1 1 Irrivation ISr Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material i Depth Q Depth Filler Material i Depth �+ TYPE,OF PTIC OR NEW INSTAy�ATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1 /SI,Lj�U f frSk`-oJ 0%,.7 \,VZAJ available within 200 feet.) F Installation will serve: Residence— Commercial— Other Number of living units: '' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal �.. ,. .. Distance to nearest: Well Foundation Property Line E l LEACHING LINE LI No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMS Ll Distance to nearest: Well Foundation Property Line F DISPOSAL PONDS ❑ I I hereby certify that 1 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 all required i pections. Complete drawing on reverse side. C� -- -- Signed Title: �t�Lf-�-t`t Date: h � OR DEPARTMENT USE ONLY S c, k - Application Accepted byA A Data3 Arae �� Ph o 01spection by Date Final Inspection by Date Additional Comments &kz-aw // .%�`�./'�1.��D//��.��'�.s 'rte .�/F.G-J'a2 -` 01 . Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DILE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 113-24 4-MIREV.1iMs1 p- � , °° � , �- �c�3 fM 1�•7a