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IPPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 and Regulations of San Joaquin County Public Health Services. eF,�,/��`///r/ Job Address �' f t- /'City d� Lot Size/Acreage /1 ^ _ Owner's Nam A' f-It "Lrly jlj Address �]-TQ�E G-1� ��//'d Phonjta9 - 9Y--e( 36 Contractor .t"ccc� Address �" -��Li�ceense 74e'� �� Phone C1 TYPE OF WELL UMP; NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 9 OTHER ❑ Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public 1-1 Other fl Delta Depth of Grow Seal Type of Grout I I Irrrgatron _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done V Type of Pump, / H.P. Z State ork D ne Well Destruction ❑ Well Diameter Sealing Material i IMptil s,,y2LP- i� F. Depth Filler Material i depth Yh ( /< IS-c—9w, TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I (No 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 wa to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �\ , PKG. TREATMENT PLT. ❑ MothPAYMENT —Rv\ Distance to nearest: Well Foundation Property LiRECEIV D LEACHING LINE ❑ No. 6 Length of lines Total length/size GR 2 9 1993 ��YY CC FILTER BED ❑ Distance to nearest: Well Foundation Prope%AWnn jf_CQU NT PI IRI If HEALTH SERViC'FS SEEPAGE PITS 11 Depth Size NUmbo,ENVIRON MENTAL HEALTH DIV1bi&,' SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby conify 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 subcontracting 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 compensa- tion laws of California." The applicant must call for MJ req inspections. Complete drawing on reverse,s,yedip //�Q�% Signed �� L 4'kv-�,-� Title: D'—" �7d�L Date: R DEP EONLY Application Accepted by Dale as Pit or Grout Inspection by Data Final Inspection by Cr-�' 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 CK H RECEIVED BY O TE PERMIT'NO.