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APPLICATION FOR PERMIT so SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOC%TON, CA 95201 �'- Goo, (209) 406-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y ` (Complete in Triplicate) 0a" Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is lade in ccmyliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pu 'Sc Healthy�S7erviicc/1es�{ Job Address�(/�t'L.�-17 CJ ` l .U/ Ih 16t��ICJ� fr� Cit Lot Size/Acreage � y/ /� �{ r Owner's Noma F� IO- ldd ( JUTA Address I s 01DAi Elk)(V • Phone aaaalNl racloru ~V--� Yl_Ca/1 ess �6 L' ML 11W.License No. Phone TYPE OF WELL/PUMP: NEW W bk ❑///''' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ _ PUMP INSTALLATION. SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 17 DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing yQDomestic/Private L) Gravel Pack ❑ Tracy Type of Casing Specifications Public 1:1 Other ❑ Delta Depth or Grout Seal Type of Grout ❑ Irrigation _Approx. De th Ea ternlurlacs Seal Installed b Ig Repair Work Done U Type of Pum H.P. "r 2t t nTtE Well Destruction O Well Diem t r, Sealing Material i Depth M(�- Depth 1 Piller Material i Depth TYPE OF SEPTIC WORK, NEW INSTALLATION ❑ REPAIR/ADDITION M DESTRUCTION G (No septic system permittedqsewe, available within 200 faet.l Installation will serve: Residence_ Commercial_ Other � Number of Irving units: _ Number of bedrooms Character of &oil to a depth of 7 feet: Water table depthSEPTIC TANK ❑ .Type/Mfg Capacity No. Compartmentse. PKG. TREATMENT PLT. ❑ Method of DisposalDistance to nearest: Well Foundation Properly Line 4 LEACHING LINE ❑ No. g Length of lines Total length/sire FILTER BED [.l Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number 3 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and a. rules and regulations of the San Joaquin County Home owner or licensed agent's signature cemittes 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 certifies the following: -I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa. tion law I Catto 6Is.- aer The appl n (I}}III rr,a/ll required inspections. Complete drawing o versa si Si no ` L(r'"-'(L�-J �'L- Date: �' (DEPARTMENT USE NIL Application Accepted by _ Date / Area Pit or Grout Inspection by DateFnel Inspection by /Sl��" Date ? Additional Comments L Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTil DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STUCKTON, CA 95201 r� c. r