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(,( . APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOAQUIN, PHONE 2-d 0 { T i _t'yet"err, 445PNOSBOX 2009, STOCKTON{2CA) ].420 9520 PERMIT EXPIRES I YEAR FROM DATE S f"r (Complete in Triplicate) Application is hereby ' e Joaquin County fo{a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 2.862 and the Rules and Regulations of San Juin County Public Health Services. I 76t 2 e4r 9 City eaGot Size/Acreage '_`-s Job Address �Q Ot N P G Phone Contractor s Address License NoC�_ 3 g� Phon TYPE OF WELL/PUMP: NEW WELL)K WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Monitoring Well ❑ PUMP INSTALLATiONX SYSTEM REPAIR ❑ OTHER O ''nn DISTANCE TO NEAREST: SEPTIC TANK V10 L SEWER LINES o y e DISPOSAL FLD.^< PROP, LINE L� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS' 3 C7 industrial ;.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Privets ❑ Gravel Pack 0 Tracy Type of Casing_l� e_e_ Specifications IJ..Public4, 1 _ Cl 01her .n.Delta-^-----w--'^TDepth-of-Grout-Seal—-� -- --� Tyne f Gkou CIrrigatio�n��, 4 O Approx. 0 th I;I Eastern Surface Seal Installed ►,;. 2J Repsir Work Done U Type of Pump re_ H.P. State Work Done WPO c ❑ Wall Diameter grial i DepthDTYPTIC WORK: MEW INSTALLA710N l I REPAIR/ADDiT10N I I DESTflUCTION i I INo septic system permined if public'sewer is E available within 200 feet.l Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.-Compartments-~- PKG. TREATMENT PLT.Q Method of Disposal _-_,•,••,_,.,Distance to_neares*; Well Foundation Property Line LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS.- 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 cartifies 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 sutrcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compenss- tion laws of California." The applicant must call for all r uired inspections. Complete drawing on reverse side. Sig Title: Date: • F•fl DEPARTMENT USE ONLY i — 1 ' � Area �_ __T �i Application Accepted by 4-i'me c,.� Date Pit or(61t inspection by C / Date Final Inspection by f2-- Oats I Addhlonal Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �_� 445_ N San-Joaquin„P-O,Hox--2009, Stkn,.. CA 95201 - FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BYTE PERMiT'NO, INFO- / . EN 1y241lIEV.r/ebl � ,1 � /,✓ �� EM 14.20