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APPLICATION'FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION.. 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR.-FRQJM DATE .ISSUED I �f�-"£''n) • ccC�aEP =tJa;.•/ -�omplete in Triplicate) Z .� L Application in hereby merie_to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance.vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County +.vPublic �\Health Services. Job Address _ 1' �-.7 e>,)p ` _ S .,J4 LE WNO�_ City Lot Size/Acreage f ZE k r , ` 1 i Owner's Neme _ l'� f--- Address A d�gJ.' x hone Contractor P Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTI❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Privete ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Rpair Public 11 Other I fl Delta Depth of Grout Seal ype of GroutIrrigation _Approx. Depth I I Eastern Surface Seal Installed by Work Done U Type of Pump H.P. r State Work Done Well Destruction O Well Diameter t Sealing Material A Depth N 1 Depth Piller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No sap6c system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—! Commercial— Other i Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: WaterriP% N Wsn SEPTIC TANK. ❑ Type/Mfg Capacity No.�irtf i PKG. TREATMENT PLT.❑ Mat i Distance to nearest: Well Foundation Property LAE P Q 4 1Q9 LEACHING LINE ❑ No. B Length of lines Total lengthy 4_-UEAJ 1w _ S ! FILTER BED ❑ Distance to nearest. Well Foundation �'. �tVha ��T EAI !•iFAI TH DiViSlOtil i '[[ SEEPAGE PITS 11 Depth Size Number ; i _SUMPS SUMPS _.. . LI Distance to nearest: Well Foundation .Property Line a DISPOSAL PONDS ❑ I hereby comity that I heve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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 peso ch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foMO r1g� '1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- Non laws of ale The applican call for all requi nsWe fion . Complete drawing o to side. Signed X Title: el Q 0 Date: OR DEPARTME USE ONLY �y Application Accepted byA Date qsl C —` Z_ Area 4 Z r Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DVE AMOUNT REMITTED K RECEIVED BY GATE PERMi7 N0. I FO CASH a £N 13.24 IREV.1/0151. EN 11.2E