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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - ; P O BOX 2009, STOCKTON, CA 95201 i + (209) 468-3447 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County/Public Health Services. Job Address ��/ �� &;:::a im 19 Cit Lot Sise/Acreage X Owner's Name kq `C Address Z0/Q 2- ` �eq m f'(t l Phon 2— I (� yQ-c r ",P� 81 Contractor i* h ti� H Address Po 45f It ' 1 3 License No. acPhone7.;Z7- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR '5( OTHER O 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t. Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications p T� Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrioation _Approx. Depth Eastern S ace Seal Installed by Q Repair work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter' Sealing Material k DeptIr Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION M DESTRUCTION G INo septic syst Aperm, tted if public sewer is available w 200 lest., Installation will serve: Residence Commercial— Other Number of living units: Number bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellS F dation Property Line ) LEACHING LINE O No. & Length of lines Total length/size �v FILTER BED n Distance to nearest: We Foundation Property Line ��------- SEEPAGE PITS 11 Depth Size Num SUMPS LI Distance t rest: Well Foundation Prop Line DISPOSAL PONOS ❑ 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." Contractor's hiring or sub-contracting signature certifies the following: "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 California." The applicant mus or/yl��r/g4uiredd ii pactions. Complete drawing on reverse side. Signed X '+ GLf,K!'✓r Title: Date: /� FOR DEPARTMENT USE ONLY Application Accepted by A �a Date 1— ��9 Area a Pit or Grout Inspection by Date Final Inspection by1 e f�� C��r Date Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE Nf0 AMOUNT DUE AMOUN? CK REV REMITTED CASH RECEIVED BY DATE PERMII1l NO. EH 14.26 I FH 'r•2a v �t�+� ^ MSZ I A _C4 l-�{ Cie)