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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 • 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 vork herein described This application is made in ccuplience vith San Joaquin County Ordinance No 51+9 and 1862 and the Rules and Regulations of San Joaquin county Public }-Health _services ,lob Address ,L '�7 r3_ �[/ �� r��2� City -Sim LIC,/"t Size/Acreage _51A C "Z /GIC L i�1� SES C/ CL.B.JG E Pgino 'qZ/ Owner s Name IC�dress Con tractorlrt3��f;/fA.P�l .PJLIilK�dress j P.�o dr �Icense No ,5g!G..7,_Phone ra -v3 ov TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT C•1 DESTRUCTION Ct Out of Service Well ❑ PUMP INSTALLATION O 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 0 Industrial ❑ Open Bottom O Manteca Dia of Well Excavation 044e Dia of Well Casing •f 171 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing E- Specifications '0/0 I 1 Public n Other n Delta Depth of Grout Seal - f/i6' -_ TYI„ of GroutS6V_aJt'2 I I Irrigation Approii Depth I I Eastern Surface Seal Installed by�tto,P.Ou 1_ ZkOw - Repair Work Done U Type of Pump HP State Yl rk Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth �f Z'Cif'ir'S Su pr /3 -�/�iP Depth Tiller Material A Depth _�� $�-✓� '1D y TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet M Installation will serve Residence Commercial — Other Number of Irving unite Number of bedrooms Character of soil to a depth of 3 lest Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundatwn Property Line LEACHING LINE Cl No & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS I I Depth Sue Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ i 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 certifies the following 'I certify that in the performance of the work tot which this perrtut is issued I shall not employ any person in such manner as to becomie subject to workmen s compensation laws of California Contractor's hiring or subcontracting signatute 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 companss tion laws of California " The applicant must call for all required Ins tions Co -7awing on reverse side SignedTitle Date -2,'�`P�c FOR DEPARTMENT USE ONLY 0? co ST Application Accepted by Data Area Pit or Grout Inspection bye'�n l�_� 'r Date Final Inspection by Date Addrtional Comments _iy4lk �� D s(l X42 5 N 1EI r,& do -- Applicant - Return all copies to San Joaquin County Public Health Services Environmental health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEE QAMOUNT DUE AMOUNT REMITTED CK I 1 CASH RECEIVED BY DATE PERMIT NO H 13.24 tiuv 1/451 + U !. $ `. y Y' i • Liv• l L -1 f-��