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APPLICATION FOR PERMIT � x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONk[ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERHIT MIRES 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 coapliartce vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ �J-206 r -Q S� N �1 ��- CityS ia� 3Lot Size/Acreage CHf�llji5p t-) V.5A Pd bad 5-00� Owner's Name Zd Address 5i°tt-,1 �PS1N1 a ( A- Phone 4_ %4 ` 1t-S ��.PIOCtR fJa 1�l� If �7 r 1170 Contractor +L N c� TAd ,,,s 1 License No. S"°2 L 9 h_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C.1 DESTRUCTION-$RADut of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. ROP. LINE FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (f 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z [I Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ �} Specifications 'It,14 do 411L FI Public Cl O�r 5;1: eIta Depth of Grout Seat �� r _ Type of Grout. ----- I I Irrigation 157—D Approx. Depth I I Eastern Surface Seal Instatled by Repair Work Done U Type of Pump H.P. State Work one - Q eM Dntruc ❑ Wall Diameter Z rr Sealing Material ✓k Depth C,Zdta Zj5er-j 00 Depth Piller Material 4 Depth &L7 f Q e- 'TLS_ TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADD{TION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other -'10 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments „ PKG. TREATMENT PLT.❑ Method of Disposal D' a to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines total length/size FILTER BED ❑ Distance to rtes► Wel! Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to near ell Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the San Joaquin County Homo owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not amploV any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature unifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parse rpt to workman's compensa- tion laws of California." The applfcan must call fo sit required inspections. Complete drawing on reverse aide. -�d-;- A > Signed x �.tti. .-� Title: ��-U '7� Data: -- PARTMENT USE ONLY �j Application Accepted by y i]1x`� -- _—_ Date -7 `� Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �� Environmental Health Permit/Services /�Vl 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED EY DAT PERMIT'N0. INFO � y�� CASH 7� `��y��y.I . EN 13-24(REV.1/x6) -� .1Jv *S EH ll q S 3 EH 14-20