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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 0 BOX 2009, STOCKTON, CA 95201 r REMIT EXPIRES I YE AR FROM (Complete in Triplicate) Application is hereby bade u San Joaquin County for a permit to construct and/or install the vork herein described. This ' application is made in compliance with Ban Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations or San Joaquin County Public Healtb Services. Job Address C d. City 15 a,,/ Lot Size/Acreage ' Owner's Name /`�J7lriit/Ti� Y Address A1Ljr5e,, $?eG?�a60hone `7 Contractor ,5t+r/, ddress t&ft±96 (tense NoG7S 3 Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 Monitoring Hellfg DISTANCE TO NEAREST SEPTIC TANK '1JC ' SEWER LINES >fSQ ' DISPOSAL FLO>/So ` PROP LINE, Z$` FOUNDATION SOS AGRICULTURE WELL�L� OTHER WELL-24,5-d' PITS/SUMPS>=/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Ora of Welt Excavation p Dia of Well Casing ' .5+Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing O fvG Specifications I I Public n Other n Delta Depth of Grout Seal Oma-:E S Typs of Grout I I Inipatron ;E9 Approx Depth I I Eastern Surface Soni Installed by Repe►r Work Done U Type of Pump 04-.0'0e HIP State Work Done_ WON Destruction 17 Well Diameter Z " Sealing Material i Depth 9:9*49k."Ve- YS-SO Depth 7 S . biller Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i ;No septic system permitted if public sewer is available within 200 feet) Installation will serve Residence_ Commercial_ Other Number of 4vinp unite Number of bedrooms ' Character of soil 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 nearest Well Foundation Property Line ' LEACHING LINE ❑ No & Length of linea Total length/site FILTER BED © Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to newest Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 runts 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 perrrut is issued I shall not ' employ any person m such manner as to become subject to workman's compensation law*of California Contractor's hiring or subcontracting signature undies the following 9 certify that in the performance of the work for which this permit is iasuedr I shall employ persons subject to workman a compensa tion laws of California " The applicant nwst Call for ail required inspections Complete drawing on reverse side ' Signed Title ate Z- OR D, PARTMEN7 USE ONLY Application Accepted byW. Data Area ' Pit Of 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, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO IN 13.24IaEV iine1 t/�i �} Ek 14.10