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APPLICATION FOR PERMIT t SAN .;' -QUIN COUNTY PUBLIC HEALTH S— VICES 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) N, Application is hereby taade.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Q.' Job AddressAl U City Lot Site/Acreage 0<=)-etc `^ Owner's Name ��---- �QMIA T Address 1�C V 14UPhone Contractor ( 92 )1fn Address l `y . 8%,120A,,'�i `]f 1 11License Nam' i3 PhoneJ 9--P7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION XOut of Service Well ❑ PUMP INSTALLATION)K—j SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TD NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINE �L� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS��Q INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIICJNS 0 industrialV Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �omeslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications/f I'1 Public n Other fl Delta Depth of Grout Sea! pe of ouL I I Irrigation 0&2.Approx. Depth �I Eastern Surface Seal Installed by ] Repair Work Done L7 Type of Pump f Cl 42,.]— H.P. to Work D Well Destruction PC Wall Diameter L2 � cling Material i Depth Depth. � 110V-T S�iler Material A Depth Ott- TYPE tt-TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION [ I DESTRUCTION I I lNo seplic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence___. Commercial Other Number of living units: Number of bedrooms Character of sou to a depth of 3 feet:= 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 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS p 1 hereby certify 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 apnt'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 unifies 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 compensa- tion la"of California." The applicant must call for alt r uir spsations. Complete drawing on reverse side. r Sig Title: Se—r— L<=G :.._. . Date: ` / lqD " OR D ARTMENT USE ONLY Application Accepted by Date r Z- Area _-__ls] L Pit or t Inspection by Date�0; Fina' Inspection by Date I-V Additional Comments: toIiAz- Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 12 t0 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 N 5719, NFEFO E AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERM11'NO. . EH 13-24 111EV.1 iAs ,I EH m4.2e .Z: