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APPLICATION FOR PERMIT [ 1 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 SU (Complete in .Triplicate) Application is hereby made 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 aad Regulations of San Joaquin County Public Health Services. Lot _Size/AcreageJob Add►essI_r27aoT1 City_1UL 7Addess y a d SOwner's Name /yS 7a Contractor A M 6: Address License No. Phone ,4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION 0 of Service well L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing (-i Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Q` I'i Public I;1 Other n Delta Depth of Grout Seal Type of GroutV�} I I Inipation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H..P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Reydeuce_ Commercial_ ther v` Number of living units: _ L Number of bedrooms Q Character of soa to a depth of 3 test: Water table depth SEPTIC TANK ❑ Type/Mfg C Capacity °2� No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well !D Foundation Property Line P d LL-_qA'CHING_LINEA ,XIQo__. B Length ol_line 14&316 �oial length/size40 FILTER BED ❑ Distance to nearest: Well 14 Foundation Property Line ---�� l SEEPAGE_PITS I I Depth Size Number SUTARS& - 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, end 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 shat)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: 1 certify 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 Musp call for al r it pectio+�Comj�l@te drawin0 on reverse side. IlkSigned Title: Date: L FOR DEPARTMENT USE ONLY Application Accepted byDate -� Area .2g C-0- t Pit or Grout Inspection by ate Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED INFO ASH RECEIVED BY DATE PERMiT`Np. CASH . EH U•I/[REV.s.xA 1 �- l/y EH 14.11117