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a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009 , STOCKTON, CA 95201 (209) 468-3447 s 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 Pu Sc Health Services. g, C� . Address g,w� Job AddA 1//1D Cit Lot Size/Acreage Owner's Name �L-tel t`C.'1� ��lA.�iAddress s Phone MlYaclor NL /'`2j ass 1 License No. �2 Phone TYPE OF WELL/PUMP: NEW WE'LC ❑fff WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATIONS 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ` YMDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public 1. Other ❑ Delta Depth of Grout Seal Type of Grout- ❑ ImuaDon —Approx. De th Es tern ]urface Soul Installed b ` Repair Work Done LI Type of Pum H.P. I f/ �- Well Destmction ❑ Well Dianj r, Sealing Material 4 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION D (No septic system permitted if public sewer is available within 200 feat.l Installation will sarve: Residence_ Commercial _ Other () Number of living units: _ Number of bedrooms .1X. Character of &oil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Ul PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line m LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number 3 SUMPS LI Distance to nearest: Well Foundation Property Line Ul 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, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 cenifies 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 law f Colifo fiia." The appl a 11 f r,a'll nrequired inspections. Complete drawing o verair si T Si`d '�L�7 h. Date: �� V .FQK DEPARTMENT USENL Application Accepted by '� DateArea / Pit or Grout Inspection by Date Final Inspection by ��;7Ge v" Data j Additional Commants: _ Appllcant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AAM'�xO^UNT DUE I'AM/O.U�NT REM�LTED CCCAaSa.Hy RECEIVED 0, 11 /DATES r:PERMIT-NO. -EH 1111(AIN I'.$, yV � /✓�(,i/ er//�•(It ` EH 4-211