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II i n n APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r{� P 0 BOX 2009, STOCKTON, CA 95201 V I " PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED 1 (Complete in Triplicate) { " ` Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This FI s _ application is made-in.corsplisnee with San Joaquin County Ordinance No. 544 and.1862 and the Rules and Regulations of San (Joaquin County Public Health Services. Job Address �� - City �'`� .]ClyLJ�t Size/Acreage _ �/ Qtr �.ne('s S� f� y� 91i� r �V Name 19X7IAddrress / r U L YYr �� Phone L /Vy r- I' Gonttactor Address ) l _AL4Cense No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service well Cl f PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER O Monitoring Nell ❑ iISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE t F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of We11,Excavation Dia. of Well Casing i t n Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications - i'I Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation } _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P, State Work Done Well Destruction ❑ Welt Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I I INo septic system permitted if public sewer is r / available within 200 feet.) Installation will serve: �egidence V Commercial� Other r Number of living unit s:=� Number of be rooms'-e;2 Character of soil to a depth of 3 feet: - Water table depth EPTiC TANK. Type/Mfg _ �� r ..��e Capacity No. Compartments PKG, TREATMENT PLT,Cl: / Method of Disposal 1 Distance to nea(est: Well ad Foundation Property Line L 6 IEACHING LINE f /7 _ �r-No. & Length of lines _. Total length/size ' ALTER SED ❑ Distance to nearest: Well Foundation 4d ! Property Line SEEPAGE PITS / Depth � _Size � �r�r�7r umber SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rirlea and regulations of the San Joaquin County ' Home owner or licensed agent's signature certifies the following:g 9 g: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F Certifies the following: "I cattily that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." " the applicant must call for all req ujr id inspections. Co plate drawing on reverse side. 5igno € (y/�l� f s Title: Date: O DEPARTMENT USE ONLY / 1� + Application Accepted by Date 7-Fr �_ )) Artie or Grout Inspection by Date Z,23 Final Inspection by Dasa �L 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 FEE} INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV PATE PERMIT'NO. E l l� �U 6z�s �3 a l H U-24 IREV.t1"5) EH,..m T 7 lS� FF