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APPLICATION FOR PERMIT �j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E,S ENVIRONI[ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �Jp� P 0 BOX 2009, STOCKTON, CA 95201 �� PERMIT EXPIRES 1 YEAR FROM- DATE ISSUED, (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to conatruct and/or install the ►cork herein described. This application is wade 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 Z Sle City Lot Size/Acreage Owner's Name` 21 _G424�&Iess Phone Contractor Q.MCQ li /u �tnir Address License No. C. 3 Phone 006 TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT 7 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 _ C7 Industrial O Open Bottom,. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17-1 Domestic/Private ❑ Gravel Pack '❑ Tracy Type of Casing_ Specifications [1 Public Cl Other f 1 Delta Depth of Grout Seat Type of Grout I I Irrigation Approx. Depth 11'Eastern Surface Seal Installed by Repair Work Don* 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth r/� Depth Filler Material i Depth � J T OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permilte if public sewer is Y .ti available within 200 Installation will Residence Commercial_ Other Number of living units: ber of bedrooms Character of soA to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg acity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: W FoundaU Property Lina �7 TEACHING LINE ❑ No. � L* of linea F Total len ize FILTER SED ❑ Ce to nearest: Well Foundation Property SEEPAGE PIT 11 Depth Size Number SUMP Ll Distance to nearest: Well Foundation Property Lina OSALPONDS ❑ 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 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."Contractors hiring or sub-contracting signature certifies the following: "1 e i at in tM performance of the'work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applic must tali f c►s• Complete drawing on r ver side. ,/ Signed Title:�� [� Data: �� -ZZ-7� OR DEPARTMENT USE ONLY 4 Application Accepted by & cz�f) Ah,,.,� -_-- Date -9 Area 0 Pit or Grout Inspection by Date Final Inspection by �• Date 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 FEE INFO AMOUNT OUE %AMOUNT REMITTED K RECEIVED BY DA;E PERMITNO. ♦ EN M24 fREY.liRai EH14-2p