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APPLICATION FOR PERMIT SAN JOAQUIN 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 I 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 `PuL Public Health Services. c , Job Address 3 ` �• a - c]am✓12 W- ��- -- ._ City Lot Size/Acreage ✓Owner's Name Address /�t �� C'.h Phone Contractor_ dw!`g==Z- Address License No. Phone TYPE OF WELL/P.UMP.:., ` t< NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of service Well ❑ F MP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nonitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial , O Open Bottom ❑ Manteca Dia. of Well Exdivation Dia. of Well Casing W 177 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public 1-1 Other h1 Delta Depth of Grout Seat Type of Grout • 5 I I Irduation ____ Approx. Depth t I Eastern Surface Saul Installed by Repair Work Done 13 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material.i Depth Depth filler Material i Depth NX Z TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No-septic system permitted if public sewer is vailabls within 200 feet. Installation will serve: Residence_ .Commercial_ Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK. ❑.:"T ype/Mfg Capacity�- No. CompartmentsPKG. TREATMENT PLT.❑ _ �f► Method of Disposal / b Distance to nearest: Well ,.Fo�ndation Property Line LEACHING LINE Cl No. b Length'of-lines' _-�"� Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Sizer Number .{ SUMPSL'I Distance to nearest: Well Foundation Property Line DISPOSAL P N15-s ❑ I homtVy 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 subcontracting signature ' certifies the following: ''f 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." The applicant must all for all required losgiections, Complete diawing on reverse side. f Signed '# Title: Date: F FOR DEPARTMENT USE ONLY F � ilv• LL= Application Accepted by a Date c Area { Pit or Grout Inspection by Date Final Inspection by � Date, r Additional Comments: Applicant _ Return all copies to: San Joaquin Count blit Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED S ECEIVEO BY DATE PERmirivO. INFO j� F a EH 13.24 rf11iV.1/115! i ] '/J �� .�J U EH 14-26 ddd///