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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, 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 vork herein described. This application 14 Made in Coispliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /�_ Job Address �y� ��c.>I�i.,ttYSEi City Lot Size/Acreage _ Owner's Name�ll}-Gt'1AGL Address ,SSS E of • hon Contracts Address License No. ylt�_Qn Phone TYPE OF WEL UMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well In PUMP INSTALLATION ❑ SYSTEM REPAIR 9 OTHER O Monitoring Well ❑ 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 ❑ Induinrief ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IT Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications I Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Oepth I Eastern Surface Seal Installed by Repair Work Done 4 Type of Pum _ H.P. 2- Stat Work D n Well Destruction ❑ Well Diameter Sealing Material i Dept !r-�/�1 tel_ Depth Filler Material a Depth M4af av S:7619 �Tl TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted it public sewer is ` ^ available within 200 feet.1 Installation will ssrw: Residence_ Commercial_ Other R Number of living units: ` Number of bedrooms - Character of we to a depth of 3 feaC Water bbl's depth SEPTIC TANK ❑ Type/M}p Capacity No. Compartments cl ' PKG. TREATMENT PLT.❑ MethpAYNIE Distance to Merest Well Foundation r Property Li R D 1 LEACHING LINE ❑ No. b Length otlifar r Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Prope6AN .0)jNTY SERVICESPI IRI W, HFALTH SEEPAGE PITS 11 Depth Sire NumberENVIRONMENTAL HEAUH OIViSIO SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, arta rules and regulations of the Sen 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, 1 shall not employ any person in such mennar 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 perlomanc•of the work for which this permit is issued, I shall employ persons subject to workman's compent a- tion laws of California." The applicant must call ffo_r�ajl) r Inspections. Complete drawing on reverse ted . Signed Title: /7aGL/ Date: S1�,9 fOR DEP NLY Application Accepted by (O1 ��' D to -�� as Pd or Grout Inspection by Date Final Inspection by Deter Addit o al Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servlcee 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED by D TE PERMIT NO. EH 11111aEV.ern e� I EH t1 ala