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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES g! N ` �j l�F p.~'11,E '�HNp I RONMIs'HtTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONES (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1—YE FROM DATE ISSUED I( (Complete in Triplicate) I Application 1s hereby Sade to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade 1n Coa>Dliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address r�� _. City Lot Size/Acreage Owner's Name ddress Phone Contraclor ltrtt 12 1' Address License No.L2.yt29 Phone TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT f. DESTRUCTION 0 Out of Seryiee Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well CJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION ' "-AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y L7 Industrial CJ Open Bottom C1 Manteca ; Dia. of Well Excavation Dia, of Wed Casing f.1 Domestic/Private ❑ Gravel Pack �,❑ Tracy ' Type of Casing__ Specifications I i I') Public j� Other �! Cl Delta s Depth of Grout Sea! Type of Grout 4� ,t t . I Irrigation `Approx.'Depth I I Eastern f Surface Seal Installed by Repair Work Done U Type of Pump H.Pi State Work Done — 1 Well Destruction Q Well Diameter ming Material i Depth Depth Filler Material t Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Iff REPAIR/ADDtTION t I DESTRUCTION I I (No septic system permitted if public sewer is _ available within 200 feet.) Installation "serve: Residence L Commercial_ Other Number of iitring units: � Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg _p.Lr 'f Capacity No. Compartments PKG. TREATMENT PLT. ❑ i" ` _ Method of Disposal Dwance to nearest: Well 1 6 Foundation�� Property Line LEACHING LINE ❑ No. A Length of lines Total.langth/siza FILTER BED ❑ Distance to rtaerent: Well JL_15 Foundation !t!D Property Line _ SEEPAGE PITS I 1 Depth Number h SUMPS LI Distance to nearest: Well Foundation T Rra `Property Lit,_ J�O DISPOSAL PONDS O j 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 `- �I Home owner or licensed agent's signature certifies the lollowing: "I certify that in Mie performance of the work for which this permit is issued, I shell not 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature canities the following: "I Certify that in the pertormance of the work for which thisrmit is issued, I shall employ Pa pl y pereans subject to workman's compensa- tion Laws of California," The applicsrtt st all for au req!n Inspections. Co lete drawing on reverse side. Signed Title: . Date: - F ti F R DEPARTMENT USE ONLY Ly Application Accepted by Date 12 F�Z Area o Z Pit or Grout( rsPactiom by Date Final Inspection by�' � �� Date� t Additional Cortxnents: IF Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services N 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFOFEECK a EN 14-36 -5 NJAMOU/NT OVE AMOUMT REMITTED CASH RECEIVED BY DATE PERMIT NO. EM 13-24 IlIEV.If R5) 1`�-/ t p (� QQ1150 �' r