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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 0 BOX 2009,[[ STOCXTON, CA 95201 t PERMIT EXPIRES 11YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made,to San Joaquin County for a permittp construct and/or install the work herein described. This application in aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ Job Address y � �✓ 4)2 JP- d4= City S /A Lot Size/Acreage Owner's Name /13,r ��Ac y Address ' Phone s� Contractor t Lf+LL 66k" rens �T -350 LCA•CL"� ,(pry{ No. 3"Phone ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I1 Public fl Other F1 Delta Depth of Grout Seal Type of Grout Q' I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by N Repair Work Done ❑ Type of Pump H.P. State Work Done_ Weal Destruction ❑ Wall Diameter Sealing Material a Depth 013 Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I TRUCTION I I INo septic system permitted if public saws, is available within 200 leet.l t7J Instaaatlon will serve://' Residence V Commercial Other Number of Bving unit!: _ Number of rpms� Character of Boll to a depth - - feet: Water table depth s. SEPTIC TANK. ❑ T yp./Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE tih:d Length of lines ' To lengthlsize FILTER BED ❑ Distance to nearest: Wall fFoundation // Property Line SEEPAGE PITS IIlitSspth Sire Number SUMPS LI Distance to merest: Well Foundation a :5 Property Lina DISPOSAL PONDS ❑ 1 hereby certify that I hews prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin County Hone 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature unifies the lollcwing: "I unity,that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- ws of Calilor a:' .. The applu calulrare drawing d �� Title; Date: L - �� F DEPARTMENT USE ONLY (� Application Accepted by Date Area , I�"pp_\' /PII or Grout Inspection by -- Dateft' Final Impaction by �* '' Date (Z 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 INFO AMOUNT DUE AMOUNT REMITTED I CCAKSH I RECEIVED BY DATE PERMIT NO. ' 1w ice%IRev.rrwal I I 'ArGTl V `i"r ^.'y // f-I� /'f_'_� '7 -7ft C 73--ri_70 1