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• APPLICATION FOR PERMIT ' ,y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT R%PIRES 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 Sap Joequin County Ordinance So. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public'B/5P smith Service � Job Address /O 7�` Al, Ciry Lot SS a/Acreage Owner's Name e Address) D�y//�� l0/? ` Phonuie ConHact �"�� , Address �7 g. F��sZ ' J —License N04KTZ ' Phon TYPE OF WELL/PUMPS NEW WEL WELL REPLACEMENT I I DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES/� DISPOSAL FLO`.. ,�,, PROP. LINE FOUNDATION.�� AGRICULTURE WELL ar�y� OTHER WELLeJ45��- c... PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 r L) industrial C) Open Bottom El Manteca Out. of Well Excavation Dia. of Wall Casing X-10omestic/Pfhreil Okr Grovel Peck ❑ Tracy Type o1 Casing_--4 Specifications 1 I'1 Public '3❑�Other n Delta Depth of Grout Seal /P Ty�s�� Grow I I Irrigation � APProx. Depth I I Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Wall Destnlction ❑ Well Diameter Sealing Material a Depth Lr4 Depth Tiller Material i Depth TYPE OF SEPTIC ORK. NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No seplm system permitted it public sawer is available within 200 fear.)Installation wal serve mm Residen e_ Commercial _ Other Number of living units: _ Number of bedrooms Character of will to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to Merest: Well Foundation Property Line LEACHING LINE ❑ No. It Length of lines Total length/size (B FILTER BED ❑ Distance to sanest: Well Foundation Property Line I V SEEPAGE PITS If Depth Sire Number SUMPS LI Distance to rational: Well _ Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, nate laws, and rubs and rsqu4tioro of the San Joaquin County Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work tot 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 unifies the following: -I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to wontman's componss tan laws o1 Califomla." The applicant/(mat ccallf for W required inspections. Complete drawing on(rrover"(side. / p Signed X— I'I'12 Title: l�a�t-1��Otn Date: p y -^� E �T USE ONLY Application Accepted D � � R Data INI Area (;Fair �!�/ _n iG T O�� r�_ik Dais Pit or �� t Impaction by `,/� Dat Final Inspection by Z Additional Comments Applicant - Return all copies to: Sao Joaquin County Public Health Services Environmental Health Permit/Servicee 445 N Sen Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIV EO gV DATE PERMIT NO. NFO SASH FR Il24(REV.11ae1 ©0 6 2s-93 JIB / FH is