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N APPLICATION FOR PERMIT t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, 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 aside in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public /3Health Seerrvice�s.. '', [•y Job Address - 4 y� r c./.T/G /7YG- City Lot Size/Acreage Owner's Name �/ d0fflCr&71e�r Address �a�CeW C ��W _ Phone 9� Contracts G ��7 �iarG. . Address��M01 rSWie / 4V' 12& License No.zG:fS S� Phone 9/6 ' TYPE OF WELL/PUMP: NEW WELL e� WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Vell ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Mo 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 L1 Industrial ❑ Opon Sonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_'Rye Specifications I'l Public n�yiO�trher n Delta Depth of Grout Seal S� r Typo of Grout s7 26 I Irrigation •QCAppras. Depth I I Eastern Surface Seal Instilled Repair Work Done L7 Type of Pump H.P. State Work Done_ Weal Destmction ❑ Well Diameter Sealing Material a Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I 1 DESTRUCTION 111No septic system permitted it public rower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soe to a depth of 3 fest: Water table depth SEPTIC TANK. ❑ ,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth -Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby trinity that 1 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 for which this permit is issued, I shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature oenifss the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compenss- tion Laws of California." The applicant must cell for ad required inspections. Complete drawing on reverse side. Signed Title:,G' �/��u/•"L- Date: Z Da FOR DEPARTMENT USE ONLY � q� Application Accepted by = ' !! q Date 99 a-9Z_ Area Ort It Ph w Grout Inspection by Dais I�7 � L Final Inspection b .r1 / � Y Additional Comments: OWsL•le� c�fYL /i1JJU `f fu.0-� /.Af N (Ji'ray0o'� I Applicant - Return all copies to: San Joaqui County Public Health Servi es Environmental Health Permit/Services lir l�Yu 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEKFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By GATE PERMIT'NO. • EH 13-24(REV.118 al $7 00 `3 ,� 4qh `1 7 FH was U lJ /L�c�