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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1a hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is Made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Q / f Job Address - v C 7 `�s- ' (A City Cu" Got Size/Acreage Owner's Name P Address �f5 1' �sfG�GC�c /t� Phone Contractor J J� '�`r Y 'Wddress �` i�'�Aa'�a'N License No. �Phone ZVS -Z TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT t-1 DESTRUCTION L1 Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T_ _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ClIndustrial 0 Open Bottom ElManteca Die. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack L] Tracy Type of Casing_____ Specifications I1 Public 17 Other (1 Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Deptx►, �I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump 19 sr H P. � 2 State Work Done 1101 NI.-k Well Destruction D Well Diameter Sealing Materisl i Depth L& ,4, rr Depth Tiller Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.) Installation will servo: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line riQ 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 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 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, I shall employ persons subject to workman's compenes tion laws of California." The applicsn uat c I for =irinstrona. Complete drawing on reverse side./� U � p 'Signed 7L C Title: �Ji�`�z Gb'��i s `�a� Date: /�� fQ DEPTMENT USE ONLY Application Accepted by ARDate d-a3 Area �-- Pit or Grout Inspection by Date Final Inspection by AA LA DateOr - 3 Additional Comments: �4 �S�s+.«.(<-d.. 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO • F„,:: tREV,„ear P `i5�� v� 550 oz-a3 93—� 5