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APPLICATION FOR PERMIT ',z,G� SAN JOAQUIN COUNTY PUBLIC HEAT ES ENVIRONMENTAL HEALTH DIVI lop �� 445 N SAN JOAQUIN, PHONE (209) � 0 P 0 BOX 2009, STOCKTON, CA PERMIT MIRES 1 YEAR FROM D (Complete in Triplicat .) INlt �`7r Application is hereby made to San Joaquin County for a permit to construct and/ YY es application is atade in cotepliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3 a 3 o Al // City �rft Lot Size/Acreage J Owner's Name Address—'7i_� -335 Contractor ANr� r ' { SOiy AddressdD0? License No. YY9-9111 Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT it DESTRUCTION O Out of Service yell O PUMP INSTALLATION G r SYSTEM REPAIR'❑ ""t OTHER ❑ Monitoring Well. ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d C) Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Casing_,_ Specifications Q F1 Public El Other—.• =- - n Delta - Depth of Grout Seal~ Type of Grout Uj I I Irrigation T Appiox R Depth l I Eastern Surface Seal Installed by Repair Work Doix U Type of.Pump H,P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth a Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION yl REPAIR/ADDITION I I DESTRUCTION l I iNo Septic system permitted'if public sewer is available within 200 test.) I Inslallation will serve: Residence— Commercial_ Othm MebiL l�orl9 Number of Hving traits: f Number of bedrooms -3 j Character of sod to a depth of 3 feet: Water table depth t g SEPTIC TANK. I dd,Typ./Mfge rT Pe L Capacityf o O No. Compatmentsx. PKG. TREATMENT PLT,❑ Method of Disposal. t — :Olstsnce to nearest: Well !ao'f Foundation —4r" Property Line /S' LEACHING LINE 2 No, b Length of linos 3 loo • Total length/size �ot7 FILTER BED Cl Distance to nearest: Well !a a ' Fourid boil" So' Property Line moo' SEEPAGE PITS ; I I Depth` Size Number SUMPS Cl Distance to'nawest: Well` Foundation Property Line DISPOSAL PONDS ❑ t I hereby certify that I have prepared this application,and that the worKWill'bii done-in accordance with San Joaquin county ordinances, state laws, and rules and regtrlatbns of the San Joaquin County Horne t Hoe 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 shed not i employ env person in such manner as to become w t to workmen's compensation laws of California." Contractor's hiring g sig bjec pe ng or sub-contracting nature t:ertifies the foflowinp: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- tion Laws of Coliform)&. ` The epplicamt most call for ad required inspections. Cotnptete drawing on reverse side. Signed XTitle: Date: FOR DEPARTMENT USE ONLY / ,,�/f r Application Accepted by Date q t Q Area "l/(, ,, Pk or Grout Inspection by Dat Final Inspection by A-et.✓ bete Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 4 Eovironmental Health Permit/Services 445 N San Joaquin, P 0 Box-2008, Stkn, CA 85201 L L INFOEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . ENSSJ4t11tY.tinSt '� �J[,.rJ � / Yj0O t� /U // � EH 1L10 T / �j J