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� ; APPLICATION FOR PERMIT u SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 C, (209) 468-3447 PEMIT EXPIRES I YEAR 1tR0li[ DATE—I20M 1 S (Complete is 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 couplianee with San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of Ban Joaquin County rPuublic Health Services. 17 2l� Job Address IL f � a 5 � , City ac�� Lot Size/Acreage Pr I� J ._._ �1J�� fS ock _ Address f�f7L l 'r 6.$ Owner's Name �3 ,), Phone ., - - •• J ,, License rvo. 3 " Phone u # Contfacto Oj" 1 / 0 Address TYPE OF WELLlPUMP: NEW WELL 6iI WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 , PUMP INSTALLATION 0 DISTANCE TO NEAREST: SEPTIC TANK'�� SEWER LINES LW ��_ =`DISPOSAL FLD. -00+ PROP, UNE FOUNDATION _ AGRICUL'TUA,E WELL_ P°r� 'O'THER WELL— PITS/SUMP _ b!� i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S T- w f.1 Industrial ❑ Open Bottom —0 Manteca rDia. of 1Nell Excav tion -f Dia. of Well Casin Domestic/Private Gravel Pack 0 Tracy Type of Casing �� Specifications J 4615. 4SPj e"oA 1�P_[? 22EZI Public �, 11.Other 0 Delta Depth of Grout Seal )tiL?O-- -- - Typo of Grout.} G Inigallor't 2 ..Approx. Depth ( Eastam Surface Seal Installed by Repair Work Done U Type of Pump H.P, State Work Done Welt Destruction D Well Diameter Sealing Material L Depth Depth Filler Naterial.R Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0l DESTRUCTION 0 {No septic system permitted it putiiic sewer is C� available within 200 feet.) D i Installation will serve: Residence —= Commercial_,. Other Number of living units: Number of bedrooms ` Character of soil to ■ depth of 3 feet: Water table depth SEPTIC TANK E) Type/Mfg 1 Capacity No. Comparlrnenta PKG`TREATMENT PLT, C! ` F Method of Disposal Distance to nearest: Well Foundation Property Line �F LEACHING LINE 0 No. & Length of lines- � Total length/size r FILTER 13ED n Distance to nearest: Well Foundation i Property Line SEEPAGE PITS 11 Depth S40Number SUMpS 4 LI Distance to�nearesr. Well Foundation Property line DISPOSAL PONDS 0 I hereby certify that I have prepared'Ihis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and li 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 E employ any person in such manner as to become subject.to workman's compensation laws of California.- Contractor's hiring or subcontracting signature certifies the following:-1 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 California." .1. -1- `- I The applicantest c for all raquir inspections. Complete drawing on reverse. ide.�rtv R + Signed x ryj Tit{a 1°,C. 6 Date: .a. r J 2 ! 16 t T USE ONLY t Application Accepted by Data y D Area Pit or Grout Inspection-by, Date b 7'10 Final Inspection by Dats j A 7 `!d . . � AdditionalC6mments: Applicant - Return all copies to: SAN JOAQ I COUNTY PUBLIC HEALTH SERVICES ENV IRONM TAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH IiE V D BY DATE PERMIT NO, INFO QQ i EHi3,7411rEV.I/MSI �, P12 . 0 T/4- - E EH 14•ss