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APPLICATION FOR PERMIT SAN d9AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i 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 i made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Court lic H slth 71ces., Job Address aenr 1City Lot Size/Acreage Ili q3 1-Z Owner's Name I S `p 0A6 on Address Phone + h I mo, �c�or"" Addre s ense No.A Lu I(a Phone � L TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ Out of Service Well ❑ F PUMP INSTAL LA7lON SYSTEM REPAIR ❑ OTHER ❑ 14onitoring 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!94ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing' 7rustic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public , 11 Other fl Delta Depth of Grout Seal Type of Grout .I 1 Irti(jation _Approx. Depth, I i astern Surface Seal Installed by Repair Work Done L] Type of Pump ! H.P. _ State Work D Well Destruction O Well Diameter Sealing Material i Depth Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRlADDITION I I DESTRUCTION I l INo septic system permined it pubtiti sewer is available within 200 list.) Installation will some: Residence Commercial:— Other Number of living units: Number of bedrooms Character of sol!to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well, Foundation' Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest:' Woum mm Foundation Property Lina All } DISPOSAL PONDS ❑ a 1 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 certifies 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. McertifNs the foMowinq:"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 laws of Cal' rnia." The applica t call fo all r ins coons. Complete drawing on raver _side. r� ' Sip Title: /2� (/!f r-� Date: `-' FOR DEPARTMENT USE ONLY Application Accepted by khILZS Date -'9 Area Pit or Grout inspection by Date Final In by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DOE AMOUNT REMITTED CASH K 11 RECEIVED SY DATE PERMIT'NO. I . EM 13.24 t11EV, 4fly EH 4�da r tC / ✓ / t..•� r