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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! ENVIRONNMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 k P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heresy made 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. 4 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / /a N we City T G t Size/Acreage ,p J�Owner's Name' f ,v Address -F M Phone Contractor — '' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ f� f PUMP`INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEP. ANKH ER LINES DISPOSAL FLD. PROP. LINE UNDATION. AGRIC ELL OTHER WELL PITS/SUMPS ,r INTENDED USE TYPE OF WELL P AREA CONSTRUCTIO ---- 0 industrial _ ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing C-) Domestic/Priya ❑ Gra ack ❑ Tracy Type of Casing_ Specifications I'] Public Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction O Well Diameter` Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION Mo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_i Commercial— Other Number of IMng units: Number of bedrooms Character of soN to a depth of 3 feet:: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 t LEACHING LINE Cl No. i Length of lines Total length/size FILTER BED ❑ Distance torr Barest: Well Foundation Property Line SEEPAGE PITS 11 Depth # ; Sire 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 Sen 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,1 shall employ persons subject to workmen's compensa- tion laws of California." The applicant must call for M1 required ing nplions. Complete drawing on reverse 'side. �1 XsX � Title: CLW_y Date.- FOR ate:FOR DEPARTMENT USE ONLY Application Accepted by Date Z � Area / Pit or Grout Inspection by Data Final Ins tion by Date Additional Comments: Q G '7 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services + 445 N San Joaquin, P O Box 2008, Stkn, CA 85201 FEE INFO AMOUNT DUE } AMOUNT REMITTED ASR RECEIVED BY DATE PERMiT'NO. �O r ♦ EH 1e•74111EV.rine) - 12,lyle � fH 1�•la